Provider Demographics
NPI:1831649045
Name:LEATHERWOOD, NICHOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 ROSE GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:LA VERNIA
Mailing Address - State:TX
Mailing Address - Zip Code:78121-4763
Mailing Address - Country:US
Mailing Address - Phone:512-563-0597
Mailing Address - Fax:
Practice Address - Street 1:1139 E SONTERRA BLVD
Practice Address - Street 2:#205
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4347
Practice Address - Country:US
Practice Address - Phone:210-614-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily