Provider Demographics
NPI:1497957013
Name:MIDDENDORF, LEAH K (NP-C)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:K
Last Name:MIDDENDORF
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 BERMUDA CT
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-4624
Mailing Address - Country:US
Mailing Address - Phone:770-445-8865
Mailing Address - Fax:
Practice Address - Street 1:2774 COBB PKWY NW
Practice Address - Street 2:STE 201
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-3469
Practice Address - Country:US
Practice Address - Phone:678-569-0144
Practice Address - Fax:678-569-0145
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN160477363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily