Provider Demographics
NPI:1770535460
Name:REDA, LESA MARIE (FNP)
Entity type:Individual
Prefix:MS
First Name:LESA
Middle Name:MARIE
Last Name:REDA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13640 N PLAZA DEL RIO BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-876-3800
Mailing Address - Fax:623-972-9590
Practice Address - Street 1:13640 N PLAZA DEL RIO BLVD
Practice Address - Street 2:STE 210
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381
Practice Address - Country:US
Practice Address - Phone:623-876-3830
Practice Address - Fax:623-876-3934
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN097080207RG0300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q50357Medicare UPIN
104976Medicare ID - Type Unspecified
AZZ118529Medicare PIN
AZZ118528Medicare PIN
AZZ104976Medicare PIN