Healthcare Provider Details

I. General information

NPI: 1861208829
Provider Name (Legal Business Name): LEIGHLA DERGHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 HARRISON AVE
BOSTON MA
02111-1817
US

IV. Provider business mailing address

136 HARRISON AVE
BOSTON MA
02111-1817
US

V. Phone/Fax

Practice location:
  • Phone: 443-345-7316
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: