Healthcare Provider Details

I. General information

NPI: 1275568826
Provider Name (Legal Business Name): LEENA MAMMEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3186 VILLAGE DR STE 201
FAYETTEVILLE NC
28304-3979
US

IV. Provider business mailing address

3264 N EVERGREEN DR NE
GRAND RAPIDS MI
49525-9746
US

V. Phone/Fax

Practice location:
  • Phone: 910-486-5700
  • Fax: 910-486-5950
Mailing address:
  • Phone: 616-363-7272
  • Fax: 616-363-7290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301081377
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2022-02626
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: