Healthcare Provider Details

I. General information

NPI: 1205938966
Provider Name (Legal Business Name): LEESA HERRMANN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MCKINLEY AVE
CHANDLER OK
74834-1622
US

IV. Provider business mailing address

312 W 2ND ST
CHANDLER OK
74834-2065
US

V. Phone/Fax

Practice location:
  • Phone: 405-258-3040
  • Fax:
Mailing address:
  • Phone: 405-258-5439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL0020159
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: