Provider Demographics
NPI:1225760259
Name:ORTENZO, LEAH ANGELA PHILLIPS
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ANGELA PHILLIPS
Last Name:ORTENZO
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 1:37 SOLAR ST
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1535
Mailing Address - Country:US
Mailing Address - Phone:770-584-2161
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-7607
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11020504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily