Healthcare Provider Details

I. General information

NPI: 1407341233
Provider Name (Legal Business Name): LEAH KATHRYN RICHARDSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 12/31/2020
Certification Date: 12/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 MIDDLEBURY ST
GOSHEN IN
46528
US

IV. Provider business mailing address

213 MIDDLEBURY ST
GOSHEN IN
46528-2956
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-3300
  • Fax:
Mailing address:
  • Phone: 574-534-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71008163A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28204011A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: