Provider Demographics
NPI:1295126753
Name:TATE, LEONIE
Entity type:Individual
Prefix:
First Name:LEONIE
Middle Name:
Last Name:TATE
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 1:198 DOVE CIR
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1705
Mailing Address - Country:US
Mailing Address - Phone:561-312-7571
Mailing Address - Fax:561-557-8503
Practice Address - Street 1:198 DOVE CIR
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-1705
Practice Address - Country:US
Practice Address - Phone:561-312-7571
Practice Address - Fax:561-557-8503
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906718311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6906718Medicaid