Basic Information
| Provider Information | |||||||||
| NPI: | 1922393842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLINE | ||||||||
| FirstName: | LEANNE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 SAINT CLAIR AVE | ||||||||
| Address2: | JTDM FAMILY PRACTICE LLC | ||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943387 | ||||||||
| FaxNumber: | 4193949580 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 ASHEVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287129524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284358400 | ||||||||
| FaxNumber: | 8284358401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.123708 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2020-00325 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0105065 | 01 | OH | GROUP MEDICAID | OTHER | 2020-00325 | 01 | NC | NC LICENSE | OTHER | 9934723 | 01 | OH | MEDICARE GROUP PTAN | OTHER | 0106492 | 05 | OH | MEDICAID | 1184652539 | 01 | OH | GROUP NPI | OTHER |