Provider Demographics
NPI:1700119674
Name:BERNALES, LESLIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BERNALES
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:POUDRIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3703 BRICES FORD CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2429
Mailing Address - Country:US
Mailing Address - Phone:703-622-7186
Mailing Address - Fax:
Practice Address - Street 1:4213 WALNEY RD
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2923
Practice Address - Country:US
Practice Address - Phone:703-502-7000
Practice Address - Fax:703-502-7006
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001210888163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)