Provider Demographics
NPI:1144680208
Name:SEWELL, LESLIE TANNERY (NP-C)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:TANNERY
Last Name:SEWELL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:BRIANA
Other - Last Name:TANNERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:679 ORANGEBURG RD STE F
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-8914
Mailing Address - Country:US
Mailing Address - Phone:843-261-2600
Mailing Address - Fax:
Practice Address - Street 1:679 ORANGEBURG RD STE F
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-8914
Practice Address - Country:US
Practice Address - Phone:843-261-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily