Provider Demographics
NPI:1164451373
Name:WATSON-FICKEN, LEANNE E (DO)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:E
Last Name:WATSON-FICKEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LEANNE
Other - Middle Name:E
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:15740 S OUTER 40 RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-2004
Mailing Address - Country:US
Mailing Address - Phone:636-735-4268
Mailing Address - Fax:
Practice Address - Street 1:15740 S OUTER 40 RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:636-735-4268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005015459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3979002Medicare PIN