Provider Demographics
NPI:1134464373
Name:LEACH, NEVERY C (LPN)
Entity Type:Individual
Prefix:MR
First Name:NEVERY
Middle Name:C
Last Name:LEACH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W 169TH ST
Mailing Address - Street 2:2A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-2828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20514 LINDEN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-2900
Practice Address - Country:US
Practice Address - Phone:718-528-5493
Practice Address - Fax:718-525-4305
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312716164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse