Provider Demographics
NPI:1659925956
Name:LEACH, OLIVIA RAE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:RAE
Last Name:LEACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 HILL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-2317
Mailing Address - Country:US
Mailing Address - Phone:518-878-0183
Mailing Address - Fax:
Practice Address - Street 1:73 WATERBURY RD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1252
Practice Address - Country:US
Practice Address - Phone:203-527-9444
Practice Address - Fax:203-527-9332
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant