Healthcare Provider Details

I. General information

NPI: 1629236351
Provider Name (Legal Business Name): KRISTIE ANN LEAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E MONROE AVE
MCALESTER OK
74501-4815
US

IV. Provider business mailing address

1101 E MONROE AVE
MCALESTER OK
74501-4815
US

V. Phone/Fax

Practice location:
  • Phone: 918-426-7852
  • Fax: 918-426-5526
Mailing address:
  • Phone: 918-426-7852
  • Fax: 918-426-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 0082397
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: