Provider Demographics
NPI:1417942335
Name:LEIDHOLM, MICHELE (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:LEIDHOLM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:UNDERWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58576-0253
Mailing Address - Country:US
Mailing Address - Phone:701-442-3148
Mailing Address - Fax:701-442-3414
Practice Address - Street 1:87 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:UNDERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58576
Practice Address - Country:US
Practice Address - Phone:701-442-3148
Practice Address - Fax:701-442-3414
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR25469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND19621Medicaid
A63211046001OtherPREFERRED ONE
P00065098OtherRR MEDICARE
ND023494OtherBCBS
004OtherAMERICA'S PPO
ND025502OtherBCBS
A63211046001OtherPREFERRED ONE
004OtherAMERICA'S PPO