Healthcare Provider Details

I. General information

NPI: 1528738291
Provider Name (Legal Business Name): LEAH VIRGINIA IMOBERSTEG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 BLACK RIVER BLVD N
ROME NY
13440-2451
US

IV. Provider business mailing address

PO BOX 2000
EAST SYRACUSE NY
13057-4500
US

V. Phone/Fax

Practice location:
  • Phone: 315-338-7184
  • Fax: 315-339-1975
Mailing address:
  • Phone: 315-362-5129
  • Fax: 315-362-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number348532
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: