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Provider Information for 1518240456

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know

LESLIE A WAGENBERG-GRELLA M.D.

Gender: FEMALE

Individual NPI: 1518240456

Calendar   Last Updated:  2020-09-14
  Certification Date:  2020-09-14

Details

Name Value
NPI 1518240456
Enumeration Date 2011-09-27
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 120 MEDICAL BLVD SUITE 106
SPRING HILL, FL 34609-0220
United States

Phone: 352-684-1340 | Fax:
View Map External Link
Primary Practice Address 120 MEDICAL BLVD SUITE 106
SPRING HILL, FL 34609-0220
United States

Phone: 352-684-1340 | Fax: 352-684-0694
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Direct Messaging Address lgrella@directaddress.org AMR Direct Address 120 MEDICAL BLVD
SUITE 106
SPRING HILL, FL 34609-0220
United States
Other Identifiers
Issuer State Number
MEDICAID FL 006606100
Taxonomy
Primary Taxonomy Selected Taxonomy State License Number
Yes 208600000X - Surgery FL ME 110500