Provider Demographics
NPI:1902872328
Name:LEAKE, NANCY S (APRN)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:S
Last Name:LEAKE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-8760
Mailing Address - Fax:860-358-8754
Practice Address - Street 1:103 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3651
Practice Address - Country:US
Practice Address - Phone:860-358-8760
Practice Address - Fax:860-358-8754
Is Sole Proprietor?:No
Enumeration Date:2006-02-25
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001012364SP0809X
CT1012363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001012OtherAPRN CONN LICENSE
CT890000279Medicare ID - Type Unspecified