Provider Demographics
NPI:1497467641
Name:LEADETH STILLWATERS LLC
Entity Type:Organization
Organization Name:LEADETH STILLWATERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:FATIMA
Authorized Official - Middle Name:MUNA
Authorized Official - Last Name:KOROMA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:571-277-1111
Mailing Address - Street 1:1805 ROCHELLE CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5632
Mailing Address - Country:US
Mailing Address - Phone:571-277-1111
Mailing Address - Fax:
Practice Address - Street 1:712 H ST NE STE 1628
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-3627
Practice Address - Country:US
Practice Address - Phone:301-265-5922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty