Provider Demographics
NPI:1760994271
Name:REID, LEIGHA MAKENZIE
Entity Type:Individual
Prefix:
First Name:LEIGHA
Middle Name:MAKENZIE
Last Name:REID
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 1:22 MCGILL DR
Mailing Address - Street 2:
Mailing Address - City:GERRARDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25420-4028
Mailing Address - Country:US
Mailing Address - Phone:304-268-4204
Mailing Address - Fax:
Practice Address - Street 1:510 BUTLER AVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25405-9990
Practice Address - Country:US
Practice Address - Phone:304-263-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV32897164W00000X
MD52319164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
R60744812OtherBLUECROSS BLUESHIELD