Provider Demographics
NPI:1255828265
Name:LEONARD, ANGIE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:
Last Name:LEONARD
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 1:1913 KINGS ROW
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4803
Mailing Address - Country:US
Mailing Address - Phone:985-259-2521
Mailing Address - Fax:
Practice Address - Street 1:1913 KINGS ROW
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4803
Practice Address - Country:US
Practice Address - Phone:985-259-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008013282172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver