Provider Demographics
NPI:1972250009
Name:LEATHERMAN HEALTHCARE, LLC
Entity Type:Organization
Organization Name:LEATHERMAN HEALTHCARE, LLC
Other - Org Name:LEATHERMAN HEALTHCARE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GWENN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEATHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP-BC
Authorized Official - Phone:301-418-5828
Mailing Address - Street 1:118 E OAK RIDGE DR STE 2000
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-7890
Mailing Address - Country:US
Mailing Address - Phone:301-678-1839
Mailing Address - Fax:301-679-1740
Practice Address - Street 1:118 E OAK RIDGE DR STE 2000
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7890
Practice Address - Country:US
Practice Address - Phone:301-678-1839
Practice Address - Fax:301-679-1740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1164875643OtherFAMILY NURSE PRACTITIONER