Provider Demographics
NPI:1851762553
Name:WALLACE, LEANDRA (NP)
Entity Type:Individual
Prefix:MS
First Name:LEANDRA
Middle Name:
Last Name:WALLACE
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 1:20 FLEETWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-3751
Mailing Address - Country:US
Mailing Address - Phone:415-663-1082
Mailing Address - Fax:415-663-9474
Practice Address - Street 1:11150 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:POINT REYES STATION
Practice Address - State:CA
Practice Address - Zip Code:94956-9756
Practice Address - Country:US
Practice Address - Phone:415-663-1082
Practice Address - Fax:415-663-9474
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003190363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner