Provider Demographics
NPI:1861118168
Name:COGBURN, LESLEY FORDE (NP)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:FORDE
Last Name:COGBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2555 COURT DR STE 270
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2185
Practice Address - Country:US
Practice Address - Phone:704-834-4390
Practice Address - Fax:704-834-3274
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5017807363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics