Healthcare Provider Details

I. General information

NPI: 1841663119
Provider Name (Legal Business Name): LEIGH WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2015
Last Update Date: 11/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7736 ORTONVILLE RD STE A
CLARKSTON MI
48348-4483
US

IV. Provider business mailing address

5809 WOODSTONE CT
CLARKSTON MI
48348-4767
US

V. Phone/Fax

Practice location:
  • Phone: 248-625-5885
  • Fax:
Mailing address:
  • Phone: 248-707-6270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704276655
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: