Provider Demographics
NPI:1417217860
Name:LEONARDS, GERONNA MARTIN (NP)
Entity Type:Individual
Prefix:
First Name:GERONNA
Middle Name:MARTIN
Last Name:LEONARDS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GERONNA
Other - Middle Name:DEIDRE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 LAKE COVE RD
Mailing Address - Street 2:
Mailing Address - City:RAYNE
Mailing Address - State:LA
Mailing Address - Zip Code:70578-7679
Mailing Address - Country:US
Mailing Address - Phone:337-334-2525
Mailing Address - Fax:
Practice Address - Street 1:1214 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2621
Practice Address - Country:US
Practice Address - Phone:770-874-5439
Practice Address - Fax:770-874-5483
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06812363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner