Provider Demographics
NPI:1437693660
Name:FOURNIER, LEIDY (PA-C)
Entity Type:Individual
Prefix:
First Name:LEIDY
Middle Name:
Last Name:FOURNIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LEIDY
Other - Middle Name:
Other - Last Name:RUFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1900 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1471 E BELTLINE AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-4548
Practice Address - Country:US
Practice Address - Phone:616-685-3414
Practice Address - Fax:616-685-3423
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant