Healthcare Provider Details

I. General information

NPI: 1720080161
Provider Name (Legal Business Name): KERRY D LEICHTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 ERICKSON AVE
HARRISONBURG VA
22801-8555
US

IV. Provider business mailing address

5894 THOMPSON RD
HARRISONBURG VA
22802-0614
US

V. Phone/Fax

Practice location:
  • Phone: 540-433-3344
  • Fax: 540-433-0031
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101052233
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: