Provider Demographics
NPI:1225386147
Name:COFFMAN, LEANDRA M
Entity Type:Individual
Prefix:
First Name:LEANDRA
Middle Name:M
Last Name:COFFMAN
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 1:607 S VILLA DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-2535
Mailing Address - Country:US
Mailing Address - Phone:812-479-1437
Mailing Address - Fax:812-479-8378
Practice Address - Street 1:607 S VILLA DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-2535
Practice Address - Country:US
Practice Address - Phone:812-479-1437
Practice Address - Fax:812-479-8378
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001315A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100356190Medicaid