Provider Demographics
NPI:1780151605
Name:CARROLL, LEAH MARIE (PA)
Entity type:Individual
Prefix:MS
First Name:LEAH
Middle Name:MARIE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5216 SCOTLAND PL
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3063
Mailing Address - Country:US
Mailing Address - Phone:863-647-2787
Mailing Address - Fax:
Practice Address - Street 1:5216 SCOTLAND PL
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3063
Practice Address - Country:US
Practice Address - Phone:863-660-2344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant