Provider Demographics
NPI:1275094385
Name:WHITE, LEONNA (APRN, FNP-C, CFCS,)
Entity Type:Individual
Prefix:
First Name:LEONNA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:APRN, FNP-C, CFCS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 OTROBANDO AVE UNIT 30
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2272
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79 WAWECUS ST STE 101
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2182
Practice Address - Country:US
Practice Address - Phone:860-886-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8156363LF0000X
CT10.098126163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0100XNursing Service ProvidersRegistered NurseGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1275094385Medicaid