Provider Demographics
NPI:1598808156
Name:LEAVELL, KRISTINA R (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:R
Last Name:LEAVELL
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2516 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1608
Practice Address - Country:US
Practice Address - Phone:260-458-3755
Practice Address - Fax:260-458-3756
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2020-10-13
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Provider Licenses
StateLicense IDTaxonomies
IN10000742A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant