Provider Demographics
NPI:1144264821
Name:WOOLDRIDGE, LESLIE S (NP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:S
Last Name:WOOLDRIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1847
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1847
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-727-4789
Practice Address - Street 1:6401 PRAIRIE ST
Practice Address - Street 2:SUITE 1700
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-7840
Practice Address - Country:US
Practice Address - Phone:231-727-7944
Practice Address - Fax:231-724-7812
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704099434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4837110Medicaid
MIMI1763011OtherMEDICARE PTAN
MIMI1763011OtherMEDICARE PTAN