Provider Demographics
NPI:1003473083
Name:MCDONALD, LEAH KIWON
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:KIWON
Last Name:MCDONALD
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 1:4663 MERRIMAC LN
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6367
Mailing Address - Country:US
Mailing Address - Phone:757-589-9484
Mailing Address - Fax:
Practice Address - Street 1:1301 MONTICELLO AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2613
Practice Address - Country:US
Practice Address - Phone:757-515-5656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA926852343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)