Provider Demographics
NPI:1306366562
Name:LEONARD, LYDIA JORDAN (FNP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:JORDAN
Last Name:LEONARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3190 NORTHRIDGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HALE
Mailing Address - State:MI
Mailing Address - Zip Code:48739
Mailing Address - Country:US
Mailing Address - Phone:989-728-6000
Mailing Address - Fax:989-728-6003
Practice Address - Street 1:3190 NORTHRIDGE RD
Practice Address - Street 2:
Practice Address - City:HALE
Practice Address - State:MI
Practice Address - Zip Code:48739-9276
Practice Address - Country:US
Practice Address - Phone:989-728-6000
Practice Address - Fax:989-728-6003
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292824363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704292824OtherNURSE PRACTITIONER LICENSE