Provider Demographics
NPI:1922155233
Name:LEISTEN, MELIA L (CPNP)
Entity Type:Individual
Prefix:
First Name:MELIA
Middle Name:L
Last Name:LEISTEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CHILDRENS LN
Mailing Address - Street 2:GASTROENTEROLOGY
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1910
Mailing Address - Country:US
Mailing Address - Phone:757-668-7240
Mailing Address - Fax:757-668-8274
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:GASTROENTEROLOGY
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7240
Practice Address - Fax:757-668-8274
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166538363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010404274Medicaid