Provider Demographics
NPI:1902913171
Name:LEADLEY, JEANNE (RN, CPNP, IBCLC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:LEADLEY
Suffix:
Gender:F
Credentials:RN, CPNP, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6560 PLEASANTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1035
Mailing Address - Country:US
Mailing Address - Phone:269-370-1598
Mailing Address - Fax:
Practice Address - Street 1:6560 PLEASANTVIEW DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1035
Practice Address - Country:US
Practice Address - Phone:269-370-1598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158197363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
S99947Medicare UPIN