Provider Demographics
NPI:1205938966
Name:HERRMANN, LEESA (LPN)
Entity type:Individual
Prefix:MRS
First Name:LEESA
Middle Name:
Last Name:HERRMANN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-2065
Mailing Address - Country:US
Mailing Address - Phone:405-258-5439
Mailing Address - Fax:
Practice Address - Street 1:112 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-1622
Practice Address - Country:US
Practice Address - Phone:405-258-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0020159164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKL0020159OtherOKLAHOMA BOARD OF NURSING