Basic Information
Provider Information | |||||||||
NPI: | 1417322397 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEYENDECKER | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | RUTH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FORBIS | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | RUTH | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PMHNP, FNP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1910 FAIRGROVE AVE | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | OH | ||||||||
PostalCode: | 450111930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138680055 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1910 FAIRGROVE AVE | ||||||||
Address2: |   | ||||||||
City: | HAMILTON | ||||||||
State: | OH | ||||||||
PostalCode: | 450111930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138680055 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2015 | ||||||||
LastUpdateDate: | 11/08/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/08/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | COA.18443-NP | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | APRN.18443.CNP | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.