Provider Demographics
NPI:1982070785
Name:GWIN, LEAH (APN)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:GWIN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:WILFONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APN
Mailing Address - Street 1:901 PRINCE WILLIAM RD STE A
Mailing Address - Street 2:
Mailing Address - City:DELPHI
Mailing Address - State:IN
Mailing Address - Zip Code:46923-1759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 PRINCE WILLIAM RD STE A
Practice Address - Street 2:
Practice Address - City:DELPHI
Practice Address - State:IN
Practice Address - Zip Code:46923-1759
Practice Address - Country:US
Practice Address - Phone:765-564-3016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-15
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28197607A163W00000X
IN71005660A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201313300Medicaid
IN855OOtherMEDICARE