Basic Information
| Provider Information | |||||||||
| NPI: | 1306366562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | JORDAN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3190 NORTHRIDGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | HALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897286000 | ||||||||
| FaxNumber: | 9897286003 | ||||||||
| Practice Location | |||||||||
| Address1: | 3190 NORTHRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | HALE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487399276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897286000 | ||||||||
| FaxNumber: | 9897286003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704292824 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 4704292824 | 01 | MI | NURSE PRACTITIONER LICENSE | OTHER |