Provider Demographics
NPI:1093768707
Name:ROUSSEAU, LEANNE M (MD)
Entity Type:Individual
Prefix:DR
First Name:LEANNE
Middle Name:M
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-1387
Mailing Address - Country:US
Mailing Address - Phone:208-415-0299
Mailing Address - Fax:208-625-2070
Practice Address - Street 1:925 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9049
Practice Address - Country:US
Practice Address - Phone:208-618-0787
Practice Address - Fax:844-807-3782
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-6045207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1105455Medicare Oscar/Certification
IDA73065Medicare UPIN