Provider Demographics
NPI:1669027793
Name:LEETHAM, GENEVIEVE MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:MARIE
Last Name:LEETHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2280 AMERICAN LEGION BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3142
Mailing Address - Country:US
Mailing Address - Phone:208-587-3988
Mailing Address - Fax:208-587-3324
Practice Address - Street 1:2280 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3142
Practice Address - Country:US
Practice Address - Phone:208-587-3988
Practice Address - Fax:208-587-3324
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5905632-4405363L00000X
IDNP-67308363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner