Provider Demographics
NPI:1417025065
Name:ERVIEN, LEIGHANNE GENTILE
Entity Type:Individual
Prefix:MRS
First Name:LEIGHANNE
Middle Name:GENTILE
Last Name:ERVIEN
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 1:2900 MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-6956
Mailing Address - Country:US
Mailing Address - Phone:928-289-0310
Mailing Address - Fax:
Practice Address - Street 1:294 W CARLOS AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025-1846
Practice Address - Country:US
Practice Address - Phone:928-524-2123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1395174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ928393Medicaid