Provider Demographics
NPI:1700409299
Name:LEIB, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:LEIB
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 1:11042 TRENTON RD NW
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-6656
Mailing Address - Country:US
Mailing Address - Phone:330-966-5282
Mailing Address - Fax:
Practice Address - Street 1:506 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:OH
Practice Address - Zip Code:44672-1151
Practice Address - Country:US
Practice Address - Phone:330-938-2025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH293500163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool