Provider Demographics
NPI:1225318330
Name:SOPKO, LEAH (CNP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:SOPKO
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38429 LAKE SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-7009
Mailing Address - Country:US
Mailing Address - Phone:440-269-7488
Mailing Address - Fax:
Practice Address - Street 1:38429 LAKE SHORE BLVD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-7009
Practice Address - Country:US
Practice Address - Phone:440-269-7488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12361-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0057603Medicaid
OHH055170Medicare PIN