Provider Demographics
NPI:1063959518
Name:HERMANSON, LEAH (NP-C)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:HERMANSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1718 S INGRAM AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7505
Practice Address - Country:US
Practice Address - Phone:660-827-2535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF0117368363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner