Provider Demographics
NPI:1326256991
Name:LEAVER, NICOLE M (APRN BC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:LEAVER
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN BC
Mailing Address - Street 1:30 TOZER RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-5510
Mailing Address - Country:US
Mailing Address - Phone:978-712-1100
Mailing Address - Fax:978-712-1120
Practice Address - Street 1:30 TOZER RD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-5510
Practice Address - Country:US
Practice Address - Phone:978-712-1100
Practice Address - Fax:978-712-1120
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261258363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000407301Medicare PIN