Provider Demographics
NPI:1912542630
Name:DAVIS, LEANNE NICHOLE (PA)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:NICHOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LEANNE
Other - Middle Name:NICHOLE
Other - Last Name:JOHNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8244 E US HIGHWAY 36 STE 1100
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9627
Mailing Address - Country:US
Mailing Address - Phone:317-272-7500
Mailing Address - Fax:317-272-7515
Practice Address - Street 1:8244 E US HIGHWAY 36 STE 1100
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9627
Practice Address - Country:US
Practice Address - Phone:317-272-7500
Practice Address - Fax:317-272-7515
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002850A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant