Provider Demographics
NPI:1578895678
Name:SISTRUNK, LEAH MONTEZ (NP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MONTEZ
Last Name:SISTRUNK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 HILTON ST
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:NC
Mailing Address - Zip Code:28906-2814
Mailing Address - Country:US
Mailing Address - Phone:828-837-7486
Mailing Address - Fax:828-837-3983
Practice Address - Street 1:228 HILTON ST
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-2814
Practice Address - Country:US
Practice Address - Phone:828-837-7486
Practice Address - Fax:828-837-3983
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC068860363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404320Medicaid