Provider Demographics
NPI:1891230140
Name:LEESTMA, ADAM (FNP)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:LEESTMA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 N HALLECK ST
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-9553
Mailing Address - Country:US
Mailing Address - Phone:219-987-7750
Mailing Address - Fax:219-987-5750
Practice Address - Street 1:519 N HALLECK ST
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-9553
Practice Address - Country:US
Practice Address - Phone:219-987-7750
Practice Address - Fax:219-987-5750
Is Sole Proprietor?:No
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28199079A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily