Provider Demographics
NPI:1164875654
Name:LEATHERMAN, GWENN
Entity Type:Individual
Prefix:DR
First Name:GWENN
Middle Name:
Last Name:LEATHERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E OAK RIDGE DR STE 2000
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-7890
Mailing Address - Country:US
Mailing Address - Phone:301-678-1839
Mailing Address - Fax:301-679-1740
Practice Address - Street 1:118 E OAK RIDGE DR STE 2000
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7890
Practice Address - Country:US
Practice Address - Phone:016-781-8393
Practice Address - Fax:301-679-1740
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR185941207Q00000X, 163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No163W00000XNursing Service ProvidersRegistered Nurse