Provider Demographics
NPI:1063781482
Name:LEAHY, KRISTIN JAY (APN-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:JAY
Last Name:LEAHY
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:JAY
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:120 MARINA BAY CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07732-1565
Mailing Address - Country:US
Mailing Address - Phone:757-291-1543
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00343100363LN0005X
NC5006035363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care