Provider Demographics
NPI:1720565344
Name:LEAHY, MACAIRA
Entity Type:Individual
Prefix:
First Name:MACAIRA
Middle Name:
Last Name:LEAHY
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 1:1576 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-7909
Mailing Address - Country:US
Mailing Address - Phone:319-335-7440
Mailing Address - Fax:193-335-7451
Practice Address - Street 1:1576 MAIN ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-7909
Practice Address - Country:US
Practice Address - Phone:319-335-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002055231223P0221X
IA09584390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA09548OtherSTATE LICENSE
CODEN.00205523OtherSTATE LICENSE