Provider Demographics
NPI:1083239628
Name:LEONEN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LEONEN
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 1:9586 CARROLL CANYON RD APT 161
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4948
Mailing Address - Country:US
Mailing Address - Phone:858-609-9679
Mailing Address - Fax:
Practice Address - Street 1:5530 OVERLAND AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1261
Practice Address - Country:US
Practice Address - Phone:858-694-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95149697163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse