Provider Demographics
NPI:1689979916
Name:LEITCH, AMY (DNP,ARNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LEITCH
Suffix:
Gender:F
Credentials:DNP,ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MAY ST
Mailing Address - Street 2:
Mailing Address - City:MARENGO
Mailing Address - State:IA
Mailing Address - Zip Code:52301-1261
Mailing Address - Country:US
Mailing Address - Phone:319-642-5543
Mailing Address - Fax:
Practice Address - Street 1:300 W MAY ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IA
Practice Address - Zip Code:52301-1261
Practice Address - Country:US
Practice Address - Phone:319-642-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-18
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC-104144363LP0200X
IAA104144363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0076372Medicaid
IA15689OtherWELLMARK