Provider Demographics
NPI:1053657387
Name:FOLEY, LEESA D (NP)
Entity Type:Individual
Prefix:
First Name:LEESA
Middle Name:D
Last Name:FOLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 WEST MICHIGAN STREET
Mailing Address - Street 2:STE 102 N
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1140 W MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-274-1019
Practice Address - Fax:317-278-4418
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004272A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201141010Medicaid
IN201141010Medicaid
IN264430257Medicare PIN
INP01441368Medicare PIN