Basic Information
| Provider Information | |||||||||
| NPI: | 1487087664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | FUENTES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FUENTES | ||||||||
| OtherFirstName: | JESSIE | ||||||||
| OtherMiddleName: | ONDINA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3421 CONCORD RD | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174029001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178511405 | ||||||||
| FaxNumber: | 7178516969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 ROOSEVELT AVE | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 17404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7178127000 | ||||||||
| FaxNumber: | 7177678985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2013 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R205536 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | SP013065 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3002240 | 01 | PA | HIGHMARK BLUE SHIELD-FREEDOM BLUE | OTHER |