Provider Demographics
NPI:1952698250
Name:LEAKE, TREYA S
Entity Type:Individual
Prefix:
First Name:TREYA
Middle Name:S
Last Name:LEAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 S 31ST ST
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-2712
Mailing Address - Country:US
Mailing Address - Phone:631-920-0526
Mailing Address - Fax:
Practice Address - Street 1:14 BELLEMEADE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1857
Practice Address - Country:US
Practice Address - Phone:631-265-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295515-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY295515-1OtherLICENSURE NUMBER