Provider Demographics
NPI:1780043810
Name:LEACH, MICHELLE (LPN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:LEACH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CANISTEO
Mailing Address - State:NY
Mailing Address - Zip Code:14823-1120
Mailing Address - Country:US
Mailing Address - Phone:607-968-0760
Mailing Address - Fax:
Practice Address - Street 1:24 2ND ST
Practice Address - Street 2:
Practice Address - City:CANISTEO
Practice Address - State:NY
Practice Address - Zip Code:14823-1120
Practice Address - Country:US
Practice Address - Phone:607-968-0760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY292549164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse