=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154287878
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAIDAN REECE LEACH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2025
-----------------------------------------------------
Last Update Date | 12/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3790 CAPITAL AVE SW
-----------------------------------------------------
City | BATTLE CREEK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49015-8332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-979-6310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7937 CHIPPEWA ST
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024-4878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-352-7019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------