Provider Demographics
NPI:1942825872
Name:LEAKE, LARITA (AS NURSING)
Entity Type:Individual
Prefix:
First Name:LARITA
Middle Name:
Last Name:LEAKE
Suffix:
Gender:F
Credentials:AS NURSING
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9614 NE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-2514
Mailing Address - Country:US
Mailing Address - Phone:405-906-1033
Mailing Address - Fax:
Practice Address - Street 1:10404 VINEYARD BLVD STE C
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-3739
Practice Address - Country:US
Practice Address - Phone:405-463-0950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK70361164W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse