Provider Demographics
NPI:1942294574
Name:LEITHERLAND, EDNA R (FNP APN)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:R
Last Name:LEITHERLAND
Suffix:
Gender:F
Credentials:FNP APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-1019
Mailing Address - Country:US
Mailing Address - Phone:731-692-2853
Mailing Address - Fax:731-692-2367
Practice Address - Street 1:1123 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:TN
Practice Address - Zip Code:38330-1019
Practice Address - Country:US
Practice Address - Phone:731-692-2853
Practice Address - Fax:731-692-2367
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5603363L00000X
TNRN53289363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S66580Medicare UPIN