Healthcare Provider Details

I. General information

NPI: 1962913699
Provider Name (Legal Business Name): PAMELA J LEACH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SIMMONS LOOP
RIVERVIEW FL
33578-9498
US

IV. Provider business mailing address

4909 DRAWDY RD
PLANT CITY FL
33567-8629
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-8000
  • Fax:
Mailing address:
  • Phone: 813-355-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPMH06260035
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9184158
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN9184158
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: