Provider Demographics
NPI:1164964193
Name:JOHNSON, LEIGH ANNE (PA)
Entity Type:Individual
Prefix:
First Name:LEIGH ANNE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LEIGHANNE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:4895 E BAY DR UNIT 120
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-6878
Mailing Address - Country:US
Mailing Address - Phone:727-330-3988
Mailing Address - Fax:
Practice Address - Street 1:4895 E BAY DR UNIT 120
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-6878
Practice Address - Country:US
Practice Address - Phone:727-330-3988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109867363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIU263ZMedicare PIN