Provider Demographics
NPI:1720762420
Name:HEITKAMP, LEESHA MADISSON (MD)
Entity Type:Individual
Prefix:
First Name:LEESHA
Middle Name:MADISSON
Last Name:HEITKAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEESHA
Other - Middle Name:MADISSON
Other - Last Name:WALZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5225 23RD AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7927
Mailing Address - Country:US
Mailing Address - Phone:701-417-1333
Mailing Address - Fax:
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-417-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND19905207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine