Provider Demographics
NPI:1609070093
Name:LEAKE, KRISTINA ANN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:ANN
Last Name:LEAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:PETROVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:980-367-4963
Mailing Address - Fax:704-316-2558
Practice Address - Street 1:1901 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2429
Practice Address - Country:US
Practice Address - Phone:980-367-4363
Practice Address - Fax:704-384-1644
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC140987207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918497Medicaid
NC2011-00385OtherNC LICENSE
NC2011-00385OtherNC LICENSE