Provider Demographics
NPI:1003168097
Name:JOHN, LEONA LORRAINE
Entity Type:Individual
Prefix:
First Name:LEONA
Middle Name:LORRAINE
Last Name:JOHN
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:PO BOX 447
Mailing Address - Street 2:BITTER SPRINGS HSE #50
Mailing Address - City:PAGE
Mailing Address - State:AZ
Mailing Address - Zip Code:86040-0447
Mailing Address - Country:US
Mailing Address - Phone:928-660-2647
Mailing Address - Fax:928-698-3468
Practice Address - Street 1:111 HAWK COURT
Practice Address - Street 2:
Practice Address - City:PAGE
Practice Address - State:AZ
Practice Address - Zip Code:86040-0447
Practice Address - Country:US
Practice Address - Phone:928-660-2647
Practice Address - Fax:928-698-3468
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ273445215343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)