Provider Demographics
NPI:1881290989
Name:MERTZ, LEECILLE M (LPN)
Entity type:Individual
Prefix:
First Name:LEECILLE
Middle Name:M
Last Name:MERTZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LEECILLE
Other - Middle Name:M
Other - Last Name:LINNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:516 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-4106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1240 PLACE ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-4040
Practice Address - Country:US
Practice Address - Phone:541-519-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61097501LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568477297OtherTREATMENT CENTER