Provider Demographics
NPI:1275568826
Name:MAMMEN, LEENA (MD)
Entity Type:Individual
Prefix:DR
First Name:LEENA
Middle Name:
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3264 N EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9746
Mailing Address - Country:US
Mailing Address - Phone:616-363-7272
Mailing Address - Fax:616-363-7290
Practice Address - Street 1:3186 VILLAGE DR STE 201
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3979
Practice Address - Country:US
Practice Address - Phone:910-486-5700
Practice Address - Fax:910-486-5950
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI43010813772085R0202X
NC2022-026262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology