Provider Demographics
NPI:1669446910
Name:LEISER-GROSS, TERRI LYNN (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:LEISER-GROSS
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 TRUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-7252
Mailing Address - Country:US
Mailing Address - Phone:305-294-4004
Mailing Address - Fax:305-294-6043
Practice Address - Street 1:1511 TRUMAN AVE
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-7252
Practice Address - Country:US
Practice Address - Phone:305-294-4004
Practice Address - Fax:305-294-2197
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9334983363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12152659OtherMULTIPLAN
FL2075021OtherCIGNA
FL4UNO2OtherBLUE CROSS BLUE SHIELD - FLORIDA BLULE
FL1669446910OtherTRICARE
FL108745100Medicaid