Provider Demographics
NPI:1881657237
Name:LEETH, ROBERT EVERETT (FNP, PMHNP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EVERETT
Last Name:LEETH
Suffix:
Gender:M
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 W CANFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9764
Mailing Address - Country:US
Mailing Address - Phone:208-292-4006
Mailing Address - Fax:866-229-7081
Practice Address - Street 1:909 W CANFIELD AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9764
Practice Address - Country:US
Practice Address - Phone:208-292-4006
Practice Address - Fax:866-229-7081
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH19136363LF0000X, 363LP0808X
CA23345363LF0000X
AK897363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP29961Medicaid
OH0168648Medicaid