=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619352101
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEANN HARVEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2015
-----------------------------------------------------
Last Update Date | 09/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 79 RATHBONE ST
-----------------------------------------------------
City | MOUNT CLEMENS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48043-5957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-387-4870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 W ROSE CITY RD
-----------------------------------------------------
City | ROSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48654-9722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-387-4870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 4703112374
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------