Healthcare Provider Details

I. General information

NPI: 1497261002
Provider Name (Legal Business Name): KATHRYN A LEIDECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2017
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3024 NEW BERN AVE STE 307
RALEIGH NC
27610-1247
US

IV. Provider business mailing address

2920 HIGHWOODS BLVD
RALEIGH NC
27604-0010
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-7844
  • Fax:
Mailing address:
  • Phone: 877-498-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5010107
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: