Provider Demographics
NPI:1710965256
Name:LEACH, CAROLYN B (NP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:B
Last Name:LEACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917-3415
Mailing Address - Country:US
Mailing Address - Phone:434-738-6420
Mailing Address - Fax:
Practice Address - Street 1:380 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917-3415
Practice Address - Country:US
Practice Address - Phone:434-738-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024068632363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P80378Medicare UPIN
ND002401Medicaid