Provider Demographics
NPI:1669123600
Name:LEONARD, WESLEY WADE
Entity type:Individual
Prefix:
First Name:WESLEY
Middle Name:WADE
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 JARDIN DE MER PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-8609
Mailing Address - Country:US
Mailing Address - Phone:239-851-0085
Mailing Address - Fax:
Practice Address - Street 1:115 BARTRAM OAKS WALK
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-3243
Practice Address - Country:US
Practice Address - Phone:904-217-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist