Provider Demographics
NPI:1649748385
Name:MCDERMOTT, LEEANN (CRNP)
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TRIPP MNR
Mailing Address - Street 2:
Mailing Address - City:FORTY FORT
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4025
Mailing Address - Country:US
Mailing Address - Phone:570-287-1558
Mailing Address - Fax:
Practice Address - Street 1:420 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3625
Practice Address - Country:US
Practice Address - Phone:570-621-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN303680L163WE0003X
PASP019327363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP019327OtherCRNP
PARN30368LOtherRN