Provider Demographics
NPI:1922278944
Name:LEANNA, LISA MARIE (HIS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:LEANNA
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1566 W MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2274
Mailing Address - Country:US
Mailing Address - Phone:920-497-7944
Mailing Address - Fax:920-497-7877
Practice Address - Street 1:1566 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2274
Practice Address - Country:US
Practice Address - Phone:920-497-7944
Practice Address - Fax:920-497-7877
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1275-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42840000Medicaid