Provider Demographics
NPI:1881102168
Name:COODY, LEON CARROLL JR (FNP)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:CARROLL
Last Name:COODY
Suffix:JR
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:19670 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-8945
Mailing Address - Country:US
Mailing Address - Phone:574-536-8051
Mailing Address - Fax:574-343-1990
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-364-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71007856A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner