Provider Demographics
NPI:1558550327
Name:LEITZKE, KATHY ANN
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:ANN
Last Name:LEITZKE
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 1:6521 WESTGATE CIR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-1290
Mailing Address - Country:US
Mailing Address - Phone:330-704-4808
Mailing Address - Fax:
Practice Address - Street 1:6521 WESTGATE CIR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-1290
Practice Address - Country:US
Practice Address - Phone:330-704-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRU023219172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker