Provider Demographics
NPI:1689280695
Name:LEARY, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEARY
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 1:20383 STATE ROUTE 79
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:OH
Mailing Address - Zip Code:43844-9774
Mailing Address - Country:US
Mailing Address - Phone:740-294-4959
Mailing Address - Fax:
Practice Address - Street 1:20383 STATE ROUTE 79
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:OH
Practice Address - Zip Code:43844-9774
Practice Address - Country:US
Practice Address - Phone:740-294-4959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHM1600502Medicaid