Provider Demographics
NPI:1114599024
Name:PARK, LEEANNA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:LEEANNA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N HURSTBOURNE PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5185
Mailing Address - Country:US
Mailing Address - Phone:260-223-1793
Mailing Address - Fax:
Practice Address - Street 1:748 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-3766
Practice Address - Country:US
Practice Address - Phone:971-321-6544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.474349163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse