Healthcare Provider Details

I. General information

NPI: 1508829987
Provider Name (Legal Business Name): LEANNE ELIZABETH EDWARDS MA, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 S 26TH ST STE 140
PHILADELPHIA PA
19112-1613
US

IV. Provider business mailing address

405 HERITAGE DR
HARLEYSVILLE PA
19438-3958
US

V. Phone/Fax

Practice location:
  • Phone: 267-463-2288
  • Fax: 215-468-2789
Mailing address:
  • Phone: 931-252-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003859
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: