MEDICARE: FERNANDA LEACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor

General Provider Information

NPI Number	:	1871135889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FERNANDA LEACH

Provider Business Mailing Address
First Line	:	5916 E LAKE PKWY STE 285
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-4802
Country	:	US
Telephone Number	:	470-781-1209
Fax Number	:	470-200-3305

Provider Business Practice Location Address
First Line	:	5916 E LAKE PKWY STE 285
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-4802
Country	:	US
Telephone Number	:	470-781-1209
Fax Number	:	470-200-3305

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2019
Last Update Date	:	10/10/2019

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Directions to “ FERNANDA LEACH ” Practice Location

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