Provider Demographics
NPI:1023203726
Name:LEATHERWOOD, DANA JEAN (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:DANA
Middle Name:JEAN
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:JEAN
Other - Last Name:DANKANYIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1301 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2122
Mailing Address - Country:US
Mailing Address - Phone:817-250-2084
Mailing Address - Fax:
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-250-2084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX547178363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y3083OtherBLUE CROSS BLUE SHIELD
TX8K5688Medicare PIN