Provider Demographics
NPI:1467787861
Name:LEIS, BERTA (PHD, ANP-BC)
Entity Type:Individual
Prefix:
First Name:BERTA
Middle Name:
Last Name:LEIS
Suffix:
Gender:F
Credentials:PHD, ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6333 N 12TH ST UNIT 151
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-1314
Mailing Address - Country:US
Mailing Address - Phone:602-730-0307
Mailing Address - Fax:
Practice Address - Street 1:6333 N 12TH ST UNIT 151
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-1314
Practice Address - Country:US
Practice Address - Phone:602-730-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-03
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN053220163W00000X
AZAP3180363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse