Provider Demographics
NPI:1912669490
Name:LEACH, LISA ELLEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELLEN
Last Name:LEACH
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 1:3566 E IMRICH RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48642-9775
Mailing Address - Country:US
Mailing Address - Phone:989-859-8901
Mailing Address - Fax:
Practice Address - Street 1:3150 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-2310
Practice Address - Country:US
Practice Address - Phone:989-249-0929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily