Provider Demographics
NPI:1780675629
Name:PITTMAN-LEYENDECKER, MICHELLE P (CNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:P
Last Name:PITTMAN-LEYENDECKER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 VETERANS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2015
Mailing Address - Country:US
Mailing Address - Phone:320-252-1670
Mailing Address - Fax:320-255-6426
Practice Address - Street 1:4801 VETERANS DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2015
Practice Address - Country:US
Practice Address - Phone:320-252-1670
Practice Address - Fax:320-255-6426
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0952637363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0704160OtherMEDICA HEALTH PLANS
1042819OtherPREFERRED ONE
078430300OtherMEDICAL ASSISTANCE
113181OtherU CARE
950S2P1OtherBLUE CROSS BLUE SHIELD
2210957OtherARAZ GROUP
HP47689OtherHEALTH PARTNERS
500002892Medicare ID - Type Unspecified
Q25942Medicare UPIN