Provider Demographics
NPI:1346716743
Name:LEECH, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LEECH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2562 CHEVAL ST APT 107
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7634
Mailing Address - Country:US
Mailing Address - Phone:814-795-9854
Mailing Address - Fax:
Practice Address - Street 1:640 21ST ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0933
Practice Address - Country:US
Practice Address - Phone:772-299-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111751363AM0700X
FLPAX000015159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant