Provider Demographics
NPI:1063744209
Name:LEONARD, TAKESHA LA'SHAWN (NP)
Entity type:Individual
Prefix:MRS
First Name:TAKESHA
Middle Name:LA'SHAWN
Last Name:LEONARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1573
Mailing Address - Country:US
Mailing Address - Phone:716-881-6191
Mailing Address - Fax:716-881-6247
Practice Address - Street 1:2495 MAIN ST STE 466
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2135
Practice Address - Country:US
Practice Address - Phone:716-260-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404581363LP0808X
NYF336180-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03210744Medicaid