Provider Demographics
NPI:1275078495
Name:LEIVA, MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LEIVA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:EZRA
Other - Last Name:LEIVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:100 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-5918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5918
Practice Address - Country:US
Practice Address - Phone:845-282-9935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-24
Last Update Date:2016-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY323831-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse