Basic Information
| Provider Information | |||||||||
| NPI: | 1629155163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEPPINK | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAVRIL | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6201 N SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | EDMORE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488299726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178815310 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 E WARWICK DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894631101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4704220033 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 5008771120 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | P00665152 | 01 | MI | RAILROAD MEDICARE | OTHER | 1059826 | 01 | MI | MCLAREN HEALTH PLAN-COMMERCIAL | OTHER | 1059826 | 01 | MI | MCLAREN HEALTH PLAN-MEDICAID | OTHER | 0N55170016 | 01 | MI | MEDICARE PLUS BLUE | OTHER | 1059826 | 01 | MI | MCLAREN HEALTH ADVANTAGE | OTHER | 200000018089 | 01 | MI | PHP FAMILYCARE | OTHER | 200000018089 | 01 | MI | PHP | OTHER | 7399969 | 01 | MI | AETNA | OTHER |