Provider Demographics
NPI:1720659774
Name:LEITZ, STEFANIE SHANNON-SENNETT (FNP)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:SHANNON-SENNETT
Last Name:LEITZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6804 HICKORY POINT DR E
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3348
Mailing Address - Country:US
Mailing Address - Phone:734-353-0258
Mailing Address - Fax:
Practice Address - Street 1:401 HOWARD ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-2748
Practice Address - Country:US
Practice Address - Phone:269-344-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704264242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily