Provider Demographics
NPI:1700897360
Name:LEESE, CONNIE S (CNS)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:LEESE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7561
Mailing Address - Fax:317-355-6096
Practice Address - Street 1:322 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46290-4622
Practice Address - Country:US
Practice Address - Phone:765-453-8555
Practice Address - Fax:765-453-8020
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN70000185A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN600001199OtherMAGELLAN
IN000000846427OtherANTHEM BCBS
IN600001199OtherMAGELLAN