Provider Demographics
NPI:1922707504
Name:LEACOCK, NATALYA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:
Last Name:LEACOCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 LINCOLN LOG WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-7673
Mailing Address - Country:US
Mailing Address - Phone:770-940-0918
Mailing Address - Fax:
Practice Address - Street 1:3051 LINCOLN LOG WAY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-7673
Practice Address - Country:US
Practice Address - Phone:770-940-0918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN261842363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology