Basic Information
Provider Information
NPI: 1033557848
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEAKE
FirstName: KIMBERLY
MiddleName: ELLEN
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 550 S JACKSON ST FL 3
Address2:  
City: LOUISVILLE
State: KY
PostalCode: 402021622
CountryCode: US
TelephoneNumber: 5028524321
FaxNumber:  
Practice Location
Address1: 550 S JACKSON ST FL 3
Address2:  
City: LOUISVILLE
State: KY
PostalCode: 402021622
CountryCode: US
TelephoneNumber: 5028525241
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/13/2013
LastUpdateDate: 02/03/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X49311KYY Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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