=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417187857
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE E LEACH CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2009
-----------------------------------------------------
Last Update Date | 08/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1607 STATE RD 6
-----------------------------------------------------
City | VERMILION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44089-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-967-8713
-----------------------------------------------------
Fax | 440-967-1938
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 636643
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-6643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-989-3801
-----------------------------------------------------
Fax | 440-960-0264
-----------------------------------------------------
=====================================================
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 | APRN.CNP.10679
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 10679
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------