Provider Demographics
NPI:1164170213
Name:CULVERSON, LEON DEWAYNE
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:DEWAYNE
Last Name:CULVERSON
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 1:701 N SLAPPEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1413
Mailing Address - Country:US
Mailing Address - Phone:229-439-1950
Mailing Address - Fax:
Practice Address - Street 1:406 S WEST ST
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-3918
Practice Address - Country:US
Practice Address - Phone:229-246-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-16
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily