Provider Demographics
NPI:1295036192
Name:LEONARD, MISTY DAWN
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
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 1:3302 NE 130TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-7981
Mailing Address - Country:US
Mailing Address - Phone:360-977-4091
Mailing Address - Fax:
Practice Address - Street 1:2006 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2637
Practice Address - Country:US
Practice Address - Phone:360-906-0826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60071897174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist