Provider Demographics
NPI:1871269316
Name:LEONARD, SHANNON MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:LEONARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 S INDEPENDENCE MALL W STE 210W
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3325
Mailing Address - Country:US
Mailing Address - Phone:215-925-6402
Mailing Address - Fax:215-925-0262
Practice Address - Street 1:170 S INDEPENDENCE MALL W STE 210W
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3325
Practice Address - Country:US
Practice Address - Phone:215-925-6402
Practice Address - Fax:215-925-0262
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003991152W00000X
NJ270A00708200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist