Provider Demographics
NPI:1316949407
Name:LEONARD, DALLAS (ANP)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:LEONARD
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 FAUNCE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:N DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-4202
Mailing Address - Country:US
Mailing Address - Phone:508-996-3311
Mailing Address - Fax:508-996-3674
Practice Address - Street 1:39 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:N DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-4202
Practice Address - Country:US
Practice Address - Phone:508-996-3311
Practice Address - Fax:508-996-3674
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP374304Medicare PIN
MAP54399Medicare UPIN
MANP3743Medicare ID - Type Unspecified