Provider Demographics
NPI:1700162823
Name:FANDL, LEANNA CAROL (NP)
Entity Type:Individual
Prefix:
First Name:LEANNA
Middle Name:CAROL
Last Name:FANDL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LEANNA
Other - Middle Name:DIPERT
Other - Last Name:FANDL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:6615 S BOUNDARY RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-1373
Mailing Address - Country:US
Mailing Address - Phone:219-787-8662
Mailing Address - Fax:219-787-8420
Practice Address - Street 1:6615 S BOUNDARY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-1373
Practice Address - Country:US
Practice Address - Phone:219-787-8662
Practice Address - Fax:219-787-8420
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28105935A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400058809Medicare UPIN