Provider Demographics
NPI:1124541941
Name:LEAK, DEMETRIA SONJA (CNA)
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:SONJA
Last Name:LEAK
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:DEMETRIA
Other - Middle Name:SONJA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY DEPT 100
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:1032 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2800
Practice Address - Country:US
Practice Address - Phone:423-266-4588
Practice Address - Fax:865-342-0103
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN69073376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide