Healthcare Provider Details

I. General information

NPI: 1669496113
Provider Name (Legal Business Name): MARY E. LEAHY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 NOD RD STE 205
AVON CT
06001-3826
US

IV. Provider business mailing address

35 NOD RD STE 205
AVON CT
06001-3826
US

V. Phone/Fax

Practice location:
  • Phone: 860-409-1507
  • Fax: 860-409-1944
Mailing address:
  • Phone: 860-409-1507
  • Fax: 860-409-1944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: