Provider Demographics
NPI:1457974388
Name:LOVE WOOLLEY, LEEANNE MARIE (AFC LICENSEE)
Entity Type:Individual
Prefix:
First Name:LEEANNE
Middle Name:MARIE
Last Name:LOVE WOOLLEY
Suffix:
Gender:F
Credentials:AFC LICENSEE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S M 30
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-8443
Mailing Address - Country:US
Mailing Address - Phone:989-426-8517
Mailing Address - Fax:
Practice Address - Street 1:621 S M 30
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-8443
Practice Address - Country:US
Practice Address - Phone:989-426-8517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF260401827311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility