Provider Demographics
NPI:1265988539
Name:LEEDALL, KIRSTEN NICOLE
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:NICOLE
Last Name:LEEDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 N. DURBIN ST.
Mailing Address - Street 2:SUITE 235
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82602
Mailing Address - Country:US
Mailing Address - Phone:307-265-2575
Mailing Address - Fax:307-222-0614
Practice Address - Street 1:152 N. DURBIN ST.
Practice Address - Street 2:SUITE 235
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82602
Practice Address - Country:US
Practice Address - Phone:307-265-2575
Practice Address - Fax:307-222-0614
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator