Healthcare Provider Details

I. General information

NPI: 1023194859
Provider Name (Legal Business Name): SHIRLEY N LEADEM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 TREE BOULEVARD SUITE 112
ST AUGUSTINE FL
32084-5774
US

IV. Provider business mailing address

1740 TREE BOULEVARD SUITE 112
ST AUGUSTINE FL
32084-5774
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-6591
  • Fax: 904-824-8856
Mailing address:
  • Phone: 904-829-6591
  • Fax: 904-824-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME88076
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: