Provider Demographics
NPI:1861539793
Name:LEIH, DEBRA JO
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:JO
Last Name:LEIH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 N. BIGHORN
Mailing Address - Street 2:
Mailing Address - City:MOORCROFT
Mailing Address - State:WY
Mailing Address - Zip Code:82721
Mailing Address - Country:US
Mailing Address - Phone:307-756-3414
Mailing Address - Fax:307-756-9237
Practice Address - Street 1:208 N. BIGHORN
Practice Address - Street 2:
Practice Address - City:MOORCROFT
Practice Address - State:WY
Practice Address - Zip Code:82721
Practice Address - Country:US
Practice Address - Phone:307-756-3414
Practice Address - Fax:307-756-9237
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY18406163W00000X
WY18406.0179363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY115787600Medicaid