Healthcare Provider Details

I. General information

NPI: 1053536110
Provider Name (Legal Business Name): TERESA L LEATHERLAND CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 SOUTH ST
LAFAYETTE IN
47901-1416
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-742-2441
  • Fax: 765-742-2344
Mailing address:
  • Phone: 765-742-2441
  • Fax: 765-742-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number102773
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: