Healthcare Provider Details

I. General information

NPI: 1063630424
Provider Name (Legal Business Name): LEANDRE M TANKERSLEY MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 06/14/2023
Certification Date: 05/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 STATE ROUTE 668 S
JUNCTION CITY OH
43748-9745
US

IV. Provider business mailing address

3710 STATE ROUTE 668 S
JUNCTION CITY OH
43748-9745
US

V. Phone/Fax

Practice location:
  • Phone: 740-987-2053
  • Fax: 740-987-2053
Mailing address:
  • Phone: 740-987-2053
  • Fax: 740-987-2053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number33007896
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: