Basic Information
| Provider Information | |||||||||
| NPI: | 1316456981 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIBLI | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 265 7TH STREET | ||||||||
| Address2: | |||||||||
| City: | PENROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193718791 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2017 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | ACPM.0993394-NP | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | APN.0993394-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | APN.0993394-NP | 01 | CO | APN-NP | OTHER |