Provider Demographics
NPI:1003186511
Name:LEACOCK, TANYA (RN)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LEACOCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 BENBURB ST
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1453
Mailing Address - Country:US
Mailing Address - Phone:516-366-8131
Mailing Address - Fax:
Practice Address - Street 1:88 BENBURB ST
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-1453
Practice Address - Country:US
Practice Address - Phone:516-366-8131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-31
Last Update Date:2011-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY616321-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse