Provider Demographics
NPI:1700181245
Name:LEEGSTRA, SUSAN MARIE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:LEEGSTRA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33310 KLEIN
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-1953
Mailing Address - Country:US
Mailing Address - Phone:586-484-0845
Mailing Address - Fax:
Practice Address - Street 1:720 GENERAL MOTORS RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-2220
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:401-652-9787
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704156875363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily