Healthcare Provider Details

I. General information

NPI: 1942590518
Provider Name (Legal Business Name): HEATHER LEISY MD, MBA, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. HEATHER LEISY

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 X ST
SACRAMENTO CA
95817-2214
US

IV. Provider business mailing address

360 N IRBY ST
FLORENCE SC
29501-2808
US

V. Phone/Fax

Practice location:
  • Phone: 800-282-3284
  • Fax:
Mailing address:
  • Phone: 843-667-9414
  • Fax: 843-667-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberMD52531
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number193607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: