Provider Demographics
NPI:1093797185
Name:LEATHERS, MICHELLE JO (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:JO
Last Name:LEATHERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:JO
Other - Last Name:BOWMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:325 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:KY
Mailing Address - Zip Code:40033-1377
Mailing Address - Country:US
Mailing Address - Phone:270-699-9126
Mailing Address - Fax:
Practice Address - Street 1:325 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:KY
Practice Address - Zip Code:40033-1377
Practice Address - Country:US
Practice Address - Phone:270-699-9500
Practice Address - Fax:270-699-9550
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64064041Medicaid
KY0661610Medicare ID - Type Unspecified
KY64064041Medicaid