Provider Demographics
NPI:1164852745
Name:LEITHEAD, LORIN (APRN)
Entity Type:Individual
Prefix:MR
First Name:LORIN
Middle Name:
Last Name:LEITHEAD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:4095 E PONY EXPRESS PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5529
Practice Address - Country:US
Practice Address - Phone:801-429-8037
Practice Address - Fax:801-753-7476
Is Sole Proprietor?:No
Enumeration Date:2013-11-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT312206-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily