Provider Demographics
NPI:1053903898
Name:DE CARLO, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DE CARLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7616 UPPER SEGUIN RD TRLR 234
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-9773
Mailing Address - Country:US
Mailing Address - Phone:210-995-5460
Mailing Address - Fax:
Practice Address - Street 1:2040 BABCOCK RD STE 304
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4428
Practice Address - Country:US
Practice Address - Phone:210-731-9570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX160672164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse