Provider Demographics
NPI:1407050859
Name:LEISETH, JUDY ANN (NP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:ANN
Last Name:LEISETH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 COLLINS RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3256
Mailing Address - Country:US
Mailing Address - Phone:719-264-1538
Mailing Address - Fax:
Practice Address - Street 1:3208 N ACADEMY BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5161
Practice Address - Country:US
Practice Address - Phone:719-573-1388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54964163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice