Provider Demographics
NPI:1073089801
Name:LEGATES, JEREMY
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LEGATES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 WOODSEDGE LN
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:DE
Mailing Address - Zip Code:19943-9542
Mailing Address - Country:US
Mailing Address - Phone:443-710-2139
Mailing Address - Fax:
Practice Address - Street 1:1305 MCD DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4699
Practice Address - Country:US
Practice Address - Phone:302-883-2926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0054237163W00000X
DEL8-0010461363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse