Provider Demographics
NPI:1629645965
Name:LEIGH, MAKENNA
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:LEIGH
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 1:226 N LIEUALLEN ST APT 202
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2141
Mailing Address - Country:US
Mailing Address - Phone:951-553-9877
Mailing Address - Fax:
Practice Address - Street 1:875 PERIMETER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-9803
Practice Address - Country:US
Practice Address - Phone:208-885-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program