Provider Demographics
NPI:1174001747
Name:LEATZOW, GENA E (FNP)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:E
Last Name:LEATZOW
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:GENA
Other - Middle Name:ELIZABETH
Other - Last Name:MCCOMB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 37189
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3189
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:11800 SUNRISE VALLEY DR STE 700
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5315
Practice Address - Country:US
Practice Address - Phone:703-834-1473
Practice Address - Fax:703-318-7463
Is Sole Proprietor?:No
Enumeration Date:2018-08-05
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily