Provider Demographics
NPI:1972762516
Name:LEYVA, JULIENNE ELAINE (ANP)
Entity Type:Individual
Prefix:MRS
First Name:JULIENNE
Middle Name:ELAINE
Last Name:LEYVA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 W BAROUCHE
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-8699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:921 W BAROUCHE
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064-8699
Practice Address - Country:US
Practice Address - Phone:765-221-9106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002421A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01198026OtherRR MEDICARE PTAN
INM400066119Medicare PIN
IN266180124Medicare PIN