Basic Information
| Provider Information | |||||||||
| NPI: | 1770734402 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | RHONDA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | WHARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CRYSTAL BEACH DR | ||||||||
| Address2: | 121 | ||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325413527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504247320 | ||||||||
| FaxNumber: | 8504247322 | ||||||||
| Practice Location | |||||||||
| Address1: | 1279 HIGHWAY 54 W STE 220 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709912200 | ||||||||
| FaxNumber: | 7709911341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP9442154 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LW0102X | 3005739 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 7100064440 | 05 | KY | MEDICAID |