Provider Demographics
NPI:1003702689
Name:FYNAARDT, LEAH
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:FYNAARDT
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 1:13540 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-8703
Mailing Address - Country:US
Mailing Address - Phone:414-640-6402
Mailing Address - Fax:
Practice Address - Street 1:13540 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-8703
Practice Address - Country:US
Practice Address - Phone:414-640-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant