Basic Information
Provider Information | |||||||||
NPI: | 1316363252 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARCIA LEACH | ||||||||
FirstName: | GWENDOLYN | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CPNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 195 W ILLINOIS AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTHERN PINES | ||||||||
State: | NC | ||||||||
PostalCode: | 283875808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106922444 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 195 W ILLINOIS AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTHERN PINES | ||||||||
State: | NC | ||||||||
PostalCode: | 283875808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106922444 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/17/2014 | ||||||||
LastUpdateDate: | 09/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/16/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 5006800 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 8902600 | 05 | NC |   | MEDICAID |