Basic Information
| Provider Information | |||||||||
| NPI: | 1811314644 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80883 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306080883 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065498114 | ||||||||
| FaxNumber: | 7065497558 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 MATHIS DR NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062339023 | ||||||||
| FaxNumber: | 7062351585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2014 | ||||||||
| LastUpdateDate: | 06/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | RN123700 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP0808X | RN123700 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 003146775 | 05 | GA | MEDICAID |