Provider Demographics
NPI:1326403452
Name:LEAKE, ELISA
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:LEAKE
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 1:6170 LEHMAN DR STE 103
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3443
Mailing Address - Country:US
Mailing Address - Phone:719-210-8733
Mailing Address - Fax:719-597-5170
Practice Address - Street 1:6170 LEHMAN DR STE 103
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3443
Practice Address - Country:US
Practice Address - Phone:719-210-8733
Practice Address - Fax:719-597-5170
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-16
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO04K999172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker