Provider Demographics
NPI:1942485040
Name:BOYER, LEISA DIANE WILSON (MA)
Entity Type:Individual
Prefix:MRS
First Name:LEISA
Middle Name:DIANE WILSON
Last Name:BOYER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. 38
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615
Mailing Address - Country:US
Mailing Address - Phone:520-366-6204
Mailing Address - Fax:520-366-0313
Practice Address - Street 1:10385 E HWY 92
Practice Address - Street 2:PALOMINAS SCHOOL DIST
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615
Practice Address - Country:US
Practice Address - Phone:520-366-6204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3336395171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor