Provider Demographics
NPI:1235822834
Name:CAUDILL, LEEANN
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:CAUDILL
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 1:133 NOTTINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:NEWFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08344-9690
Mailing Address - Country:US
Mailing Address - Phone:732-403-4110
Mailing Address - Fax:
Practice Address - Street 1:4620 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:MAYS LANDING
Practice Address - State:NJ
Practice Address - Zip Code:08330-3213
Practice Address - Country:US
Practice Address - Phone:609-625-7301
Practice Address - Fax:609-625-7354
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3666156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician