Provider Demographics
NPI:1104195791
Name:LEITNER, AMY (LMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LEITNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-0508
Mailing Address - Country:US
Mailing Address - Phone:701-214-0204
Mailing Address - Fax:
Practice Address - Street 1:1001 GATEWAY AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0508
Practice Address - Country:US
Practice Address - Phone:701-214-0204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1019174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist