Provider Demographics
NPI:1376782128
Name:LEAHY, NATHANIEL BRANDON (LAC)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:BRANDON
Last Name:LEAHY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16821 SE MCGILLIVRAY BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-0401
Mailing Address - Country:US
Mailing Address - Phone:360-953-8740
Mailing Address - Fax:
Practice Address - Street 1:16821 SE MCGILLIVRAY BLVD STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-0401
Practice Address - Country:US
Practice Address - Phone:360-953-8740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60071465171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAC60071465OtherWASHINGTON STATE ACUPUNCTURE LICENSE