Healthcare Provider Details

I. General information

NPI: 1780675629
Provider Name (Legal Business Name): MICHELLE P PITTMAN-LEYENDECKER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-1670
  • Fax: 320-255-6426
Mailing address:
  • Phone: 320-252-1670
  • Fax: 320-255-6426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR0952637
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: