Provider Demographics
NPI:1407992779
Name:LEAHY, NANCY A (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:LEAHY
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 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-270-4812
Mailing Address - Fax:
Practice Address - Street 1:2320 N LAKE DR
Practice Address - Street 2:ROOM E2635
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4507
Practice Address - Country:US
Practice Address - Phone:414-270-4812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43966800Medicaid
WI43966800Medicaid