Provider Demographics
NPI:1922393842
Name:KLINE, LEANNE M
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:M
Last Name:KLINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:JTDM FAMILY PRACTICE LLC
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-394-9580
Practice Address - Street 1:1409 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-9524
Practice Address - Country:US
Practice Address - Phone:828-435-8400
Practice Address - Fax:828-435-8401
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.123708207Q00000X
NC2020-00325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105065OtherGROUP MEDICAID
NC2020-00325OtherNC LICENSE
OH9934723OtherMEDICARE GROUP PTAN
OH0106492Medicaid
OH1184652539OtherGROUP NPI
OH1184652539OtherGROUP NPI