Provider Demographics
NPI:1821609447
Name:LEOS, MARY KATHERINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:LEOS
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 1:2359 LIME ROCK RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA HILLS
Mailing Address - State:AL
Mailing Address - Zip Code:35216-3006
Mailing Address - Country:US
Mailing Address - Phone:205-533-3386
Mailing Address - Fax:
Practice Address - Street 1:780 JOHNSON FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1434
Practice Address - Country:US
Practice Address - Phone:404-661-6865
Practice Address - Fax:404-829-1312
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA10697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program