Provider Demographics
NPI:1841663119
Name:WILSON, LEIGH (FNP)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:
Last Name:WILSON
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 1:5809 WOODSTONE CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4767
Mailing Address - Country:US
Mailing Address - Phone:248-707-6270
Mailing Address - Fax:
Practice Address - Street 1:7736 ORTONVILLE RD STE A
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4483
Practice Address - Country:US
Practice Address - Phone:248-625-5885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-08
Last Update Date:2015-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276655363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily