Provider Demographics
NPI:1053065391
Name:LEICHTLE, MAI YANG
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:YANG
Last Name:LEICHTLE
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 1:336 PARKVIEW CT S
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-6916
Mailing Address - Country:US
Mailing Address - Phone:651-757-0187
Mailing Address - Fax:
Practice Address - Street 1:2350 CLEVELAND AVE N
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-2701
Practice Address - Country:US
Practice Address - Phone:651-757-0187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-06
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2040767163W00000X
MN9091363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse