Healthcare Provider Details

I. General information

NPI: 1679696363
Provider Name (Legal Business Name): LEANNE MAZEIKA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST STE 690
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

19 OLD HAMILTON EXT
STURBRIDGE MA
01566
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-9530
  • Fax: 508-363-9535
Mailing address:
  • Phone: 508-363-9530
  • Fax: 508-363-9535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number191914
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: