Healthcare Provider Details

I. General information

NPI: 1063949741
Provider Name (Legal Business Name): LEIGH MAE PROVENCHER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEIGH MAE JOANNE GISELE ROSA PROVENCHER

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 920-735-7645
  • Fax:
Mailing address:
  • Phone: 920-735-7645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number83019-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number83019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: