Provider Demographics
NPI:1639933609
Name:LEATHERBURY, TINA DENISE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:DENISE
Last Name:LEATHERBURY
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 1:28 REGAL WAY
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-4681
Mailing Address - Country:US
Mailing Address - Phone:757-450-3577
Mailing Address - Fax:
Practice Address - Street 1:1881 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-8083
Practice Address - Country:US
Practice Address - Phone:757-683-4297
Practice Address - Fax:757-683-5253
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program