Basic Information
Provider Information | |||||||||
NPI: | 1437645892 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS - VAZQUEZ ATECAS | ||||||||
FirstName: | LEIGH | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 21 NE ROMANCE HILL RD | ||||||||
Address2: |   | ||||||||
City: | BELFAIR | ||||||||
State: | WA | ||||||||
PostalCode: | 985288315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3602772950 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 217 N BOONE ST STE C | ||||||||
Address2: |   | ||||||||
City: | ABERDEEN | ||||||||
State: | WA | ||||||||
PostalCode: | 985207612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3606379421 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2018 | ||||||||
LastUpdateDate: | 12/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | AP60872229 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | AP60872229 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1437645892 | 05 | WA |   | MEDICAID | 83-1064079 | 05 | WA |   | MEDICAID |