Provider Demographics
NPI:1114600780
Name:LEAKE, JOHN LEWIS
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEWIS
Last Name:LEAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HAHN 3124 -- 6271 USA DRIVE NORTH
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36688-0001
Mailing Address - Country:US
Mailing Address - Phone:251-441-9334
Mailing Address - Fax:
Practice Address - Street 1:HAHN 3124 -- 6271 USA DRIVE NORTH
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36688-0001
Practice Address - Country:US
Practice Address - Phone:251-441-9334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty