Provider Demographics
NPI:1235199134
Name:LEACH, MARY KAY (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:LEACH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8202
Mailing Address - Fax:850-862-6148
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:INTERNAL MEDICINE DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-863-8202
Practice Address - Fax:850-862-6148
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9196496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305445400Medicaid