Provider Demographics
NPI:1811314644
Name:LEONARD, LORI (NP)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LEONARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80883
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0883
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:706-549-7558
Practice Address - Street 1:6 MATHIS DR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1242
Practice Address - Country:US
Practice Address - Phone:706-233-9023
Practice Address - Fax:706-235-1585
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123700363LG0600X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003146775Medicaid