Provider Demographics
NPI:1073675617
Name:CHURCH, LEONA JO'ANNE' (CPNP)
Entity Type:Individual
Prefix:DR
First Name:LEONA
Middle Name:JO'ANNE'
Last Name:CHURCH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 W FAIRVIEW AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5190
Mailing Address - Country:US
Mailing Address - Phone:208-395-0000
Mailing Address - Fax:208-395-0009
Practice Address - Street 1:1655 W FAIRVIEW AVE STE 206
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5190
Practice Address - Country:US
Practice Address - Phone:208-395-0000
Practice Address - Fax:208-395-0009
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-157A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805703400Medicaid
ID1344916Medicare ID - Type Unspecified
ID805703400Medicaid