Healthcare Provider Details

I. General information

NPI: 1578999645
Provider Name (Legal Business Name): LEAH HALLIBURTON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2013
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457-7606
US

IV. Provider business mailing address

1650 GRAND CONCOURSE OB/GYN - 5TH FL (ADMIN)
BRONX NY
10457-7606
US

V. Phone/Fax

Practice location:
  • Phone: 718-590-1800
  • Fax:
Mailing address:
  • Phone: 718-239-8383
  • Fax: 718-239-8360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number001557
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: