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General NPI Number Information
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NPI Number | 1245001791
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Entity Type | Individual
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Provider Name | MICHELLE MARIE LEIVA PA-C
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Gender | Female
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Dates
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Enumeration Date | 01/12/2024
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 601 OLD NORCROSS RD STE A
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4311
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Country | US
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Telephone | 770-284-3150
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Fax |
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Provider Business Mailing Address
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Address Line | 601 OLD NORCROSS RD STE A
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4311
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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