Provider Demographics
NPI:1891266029
Name:LEESON, EVERT LORY
Entity Type:Individual
Prefix:
First Name:EVERT
Middle Name:LORY
Last Name:LEESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7020 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-4753
Mailing Address - Country:US
Mailing Address - Phone:813-935-6111
Mailing Address - Fax:813-935-6111
Practice Address - Street 1:7020 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-4753
Practice Address - Country:US
Practice Address - Phone:813-935-6111
Practice Address - Fax:813-935-6111
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant