Healthcare Provider Details

I. General information

NPI: 1932563392
Provider Name (Legal Business Name): LEIGH ANNE COSTANZO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 E SOUTHERN AVE STE 106
MESA AZ
85204-5058
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 600
NASHVILLE TN
37205-5250
US

V. Phone/Fax

Practice location:
  • Phone: 480-610-7100
  • Fax: 480-870-7402
Mailing address:
  • Phone: 615-314-5257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number007894
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: