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General NPI Number Information
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NPI Number | 1962804120
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Entity Type | Individual
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Provider Name | LEANNE M KOVICK CFM
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Gender | Female
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Dates
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Enumeration Date | 09/19/2014
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Last Update Date | 12/07/2015
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Provider Practice Location Address
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Address Line | 2006 BLAINE ST
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City | CALDWELL
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State | ID
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Zip | 83605-4343
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Country | US
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Telephone | 208-985-5404
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Fax | 208-402-5959
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Provider Business Mailing Address
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Address Line | 2006 BLAINE ST
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City | CALDWELL
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State | ID
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Zip | 83605-4343
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Country | US
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Telephone | 208-985-5404
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Fax | 208-402-5959
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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 | 224900000X
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Taxonomy Name | Mastectomy Fitter
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License Number | CFM02746
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License Number State | ID
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