Provider Demographics
NPI:1720146962
Name:LEACH, JUDY
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:LEACH
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 1:3206 N TEMPLE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-2047
Mailing Address - Country:US
Mailing Address - Phone:317-438-5319
Mailing Address - Fax:317-438-5319
Practice Address - Street 1:3206 N TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-2047
Practice Address - Country:US
Practice Address - Phone:317-925-7844
Practice Address - Fax:317-925-7844
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200805330AMedicare ID - Type Unspecified