Provider Demographics
NPI:1568536910
Name:TYGUM, LEAH NICHOLE (AUD CCCA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:NICHOLE
Last Name:TYGUM
Suffix:
Gender:F
Credentials:AUD CCCA
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:NICHOLE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2910 CENTRE POINTE DRIVE
Mailing Address - Street 2:35 121A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2109
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:345 NORTH SMITH AVENUE
Practice Address - Street 2:CHILDRENS HOSPITALS AND CLINICS AUDIOLOGY ST PAUL
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7603231H00000X, 237600000X, 237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Not Answered237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Not Answered237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist