Healthcare Provider Details

I. General information

NPI: 1487720801
Provider Name (Legal Business Name): LEATHA M ROSS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MCCREIGHT AVE STE 110
SPRINGFIELD OH
45504-1853
US

IV. Provider business mailing address

30 W MCCREIGHT AVE STE 110
SPRINGFIELD OH
45504-1853
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-9050
  • Fax: 937-523-9059
Mailing address:
  • Phone: 937-523-9050
  • Fax: 937-523-9059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.06909
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: