Provider Demographics
NPI:1346323144
Name:LEONARD, HEATHER A
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
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 1:2000 EOFF ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-3823
Mailing Address - Country:US
Mailing Address - Phone:304-234-8663
Mailing Address - Fax:304-234-8960
Practice Address - Street 1:2000 EOFF ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3823
Practice Address - Country:US
Practice Address - Phone:304-234-8755
Practice Address - Fax:304-234-8960
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV471133V00000X
OHLD.4294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810014834Medicaid
WVP00844132OtherMCR RR
WVMT75461Medicare PIN
OHH151732Medicare PIN
OHH151730Medicare UPIN
WVP00844132OtherMCR RR