Basic Information
| Provider Information | |||||||||
| NPI: | 1417217860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARDS | ||||||||
| FirstName: | GERONNA | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | GERONNA | ||||||||
| OtherMiddleName: | DEIDRE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 205 LAKE COVE RD | ||||||||
| Address2: | |||||||||
| City: | RAYNE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705787679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373342525 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1214 COOLIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708745439 | ||||||||
| FaxNumber: | 7708745483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2012 | ||||||||
| LastUpdateDate: | 05/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP06812 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.