Provider Demographics
NPI:1376613786
Name:LEISTNER, LOIS M (ARNP)
Entity type:Individual
Prefix:
First Name:LOIS
Middle Name:M
Last Name:LEISTNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 S BLAIR STONE RD STE 128
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-8827
Mailing Address - Country:US
Mailing Address - Phone:448-500-7733
Mailing Address - Fax:
Practice Address - Street 1:130 SUNFLOWER RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32305-3558
Practice Address - Country:US
Practice Address - Phone:448-500-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1654742363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200080590AMedicaid
OK200026170BMedicaid
FLU5887ZMedicare ID - Type Unspecified
Q47114Medicare UPIN
OK248519716Medicare ID - Type Unspecified
OK200080590AMedicaid
800522325Medicare ID - Type UnspecifiedGROUP