Healthcare Provider Details

I. General information

NPI: 1801242714
Provider Name (Legal Business Name): LEEANN BUZZERD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17548 VETERANS MEMORIAL HWY
KINGWOOD WV
26537-9797
US

IV. Provider business mailing address

17548 VETERANS MEMORIAL HWY
KINGWOOD WV
26537-9797
US

V. Phone/Fax

Practice location:
  • Phone: 304-441-2001
  • Fax: 304-441-2009
Mailing address:
  • Phone: 304-441-2001
  • Fax: 304-441-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number79445
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: