Provider Demographics
NPI:1457510570
Name:LEAK, TAMMY SUE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TAMMY
Middle Name:SUE
Last Name:LEAK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 HARRISON AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-3403
Mailing Address - Country:US
Mailing Address - Phone:513-894-7313
Mailing Address - Fax:
Practice Address - Street 1:7390 ROLLING MEADOWS DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-1286
Practice Address - Country:US
Practice Address - Phone:513-755-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN102252164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2359399Medicaid