Healthcare Provider Details

I. General information

NPI: 1982994562
Provider Name (Legal Business Name): HEATHER LEATH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE SUITE 103
PADUCAH KY
42003-3817
US

IV. Provider business mailing address

PO BOX 7309
PADUCAH KY
42002-7309
US

V. Phone/Fax

Practice location:
  • Phone: 270-415-4860
  • Fax: 270-415-4862
Mailing address:
  • Phone: 270-744-9600
  • Fax: 270-744-0834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3006881
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: