Provider Demographics
NPI:1154679249
Name:LEIS, NAOMI (LPN)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:
Last Name:LEIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6743 NAUTILUS AVE
Mailing Address - Street 2:
Mailing Address - City:CASHTON
Mailing Address - State:WI
Mailing Address - Zip Code:54619-7247
Mailing Address - Country:US
Mailing Address - Phone:608-487-5472
Mailing Address - Fax:
Practice Address - Street 1:510 N COURT ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1708
Practice Address - Country:US
Practice Address - Phone:608-633-2817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304764-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse