=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265211924
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEANNE N CONCORDIA CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2023
-----------------------------------------------------
Last Update Date | 09/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 22ND ST S FL 3
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35233-3110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-975-1016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2858 THORNHILL RD APT 71B
-----------------------------------------------------
City | MOUNTAIN BRK
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35213-4045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-577-2412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-143795
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------