Healthcare Provider Details

I. General information

NPI: 1568048585
Provider Name (Legal Business Name): LISA A LEIDY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2021
Last Update Date: 03/21/2021
Certification Date: 03/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 S STATE STREET ALY
DOVER DE
19904-7348
US

IV. Provider business mailing address

156 S STATE STREET ALY
DOVER DE
19904-7348
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-2380
  • Fax:
Mailing address:
  • Phone: 302-674-2380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0067103
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: