Provider Demographics
NPI:1790151355
Name:LEEDER, ANN MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:LEEDER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4820
Mailing Address - Country:US
Mailing Address - Phone:866-389-2727
Mailing Address - Fax:
Practice Address - Street 1:3710 57TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4820
Practice Address - Country:US
Practice Address - Phone:414-526-9024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI169833163W00000X
WI6701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse