Provider Demographics
NPI:1477129559
Name:WHEATON, LEAH ANTOINETTE
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ANTOINETTE
Last Name:WHEATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 ALLDS ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-4745
Mailing Address - Country:US
Mailing Address - Phone:603-886-5506
Mailing Address - Fax:
Practice Address - Street 1:74 ALLDS ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-4745
Practice Address - Country:US
Practice Address - Phone:603-886-5506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2322369207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF03210630OtherAANP CERTIFICATION NUMBER