Basic Information
| Provider Information | |||||||||
| NPI: | 1588063754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOVALICK | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 CENTRAL DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197189512 | ||||||||
| FaxNumber: | 9197189516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2014 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 18227 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 363LP0200X | 5007064 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 228065 | 01 | NC | RN PERMANENT LICENCE | OTHER | 5007064 | 01 | NC | NURSE PRACTITIONER | OTHER |