Provider Demographics
NPI:1508481110
Name:KOMISAK, LEAH RENEE
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:RENEE
Last Name:KOMISAK
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 1:4269 TYNDALL AVE BLDG 282
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6074
Mailing Address - Country:US
Mailing Address - Phone:810-358-3817
Mailing Address - Fax:
Practice Address - Street 1:4269 TYNDALL AVE BLDG 282
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6074
Practice Address - Country:US
Practice Address - Phone:810-358-3817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAT-3522255A2300X
NH14572255A2300X
NVAT05067702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer