Provider Demographics
NPI:1952619512
Name:LEEPACK, LYNETTE LEOLA (NP)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:LEOLA
Last Name:LEEPACK
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 1:19 BOTANY LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2519
Mailing Address - Country:US
Mailing Address - Phone:631-721-8065
Mailing Address - Fax:631-638-0660
Practice Address - Street 1:3 EDMUND D PELLEGRINO RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-9460
Practice Address - Country:US
Practice Address - Phone:631-638-0693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302648363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health