Provider Demographics
NPI:1972647113
Name:CLEMENCE, LEAH C (RN)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:C
Last Name:CLEMENCE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26629 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:WIND LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53185-1345
Mailing Address - Country:US
Mailing Address - Phone:262-895-2058
Mailing Address - Fax:
Practice Address - Street 1:26629 RICHARD DR
Practice Address - Street 2:
Practice Address - City:WIND LAKE
Practice Address - State:WI
Practice Address - Zip Code:53185-1345
Practice Address - Country:US
Practice Address - Phone:262-895-2058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WH0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35011900Medicaid