Healthcare Provider Details

I. General information

NPI: 1912519042
Provider Name (Legal Business Name): LEAH GRACE GAWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 N SAN PEDRO ST
BENSON AZ
85602-6194
US

IV. Provider business mailing address

595 N SAN PEDRO ST
BENSON AZ
85602-6194
US

V. Phone/Fax

Practice location:
  • Phone: 623-565-1539
  • Fax:
Mailing address:
  • Phone: 623-565-1539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number229935
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: