Provider Demographics
NPI:1982994562
Name:LEATH, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LEATH
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:PO BOX 7309
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7309
Mailing Address - Country:US
Mailing Address - Phone:270-744-9600
Mailing Address - Fax:270-744-0834
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3817
Practice Address - Country:US
Practice Address - Phone:270-415-4860
Practice Address - Fax:270-415-4862
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100239080Medicaid
KY7100239080Medicaid
KYP01310836Medicare PIN