Healthcare Provider Details

I. General information

NPI: 1538075148
Provider Name (Legal Business Name): LELAND COREY PRETTY WEASEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 HAINES AVE NE APT 30
ALBUQUERQUE NM
87110-5265
US

IV. Provider business mailing address

5801 HAINES AVE NE APT 30
ALBUQUERQUE NM
87110-5265
US

V. Phone/Fax

Practice location:
  • Phone: 505-391-8450
  • Fax:
Mailing address:
  • Phone: 505-391-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: