Provider Demographics
NPI:1043697873
Name:LEACOCK, JOELLE (CNM)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:
Last Name:LEACOCK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 LACIMA RD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5739
Mailing Address - Country:US
Mailing Address - Phone:617-216-1398
Mailing Address - Fax:
Practice Address - Street 1:3741 RUTLEDGE RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-5566
Practice Address - Country:US
Practice Address - Phone:505-798-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN270093367A00000X
NM844367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife