Provider Demographics
NPI:1104597244
Name:OWENS, LEAH ANTOINETTE (MS, CCM)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ANTOINETTE
Last Name:OWENS
Suffix:
Gender:F
Credentials:MS, CCM
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:ANTOINETTE
Other - Last Name:GRISWOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24 POULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4500
Mailing Address - Country:US
Mailing Address - Phone:813-847-4226
Mailing Address - Fax:
Practice Address - Street 1:24 POULTON DR NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4500
Practice Address - Country:US
Practice Address - Phone:813-847-4226
Practice Address - Fax:850-601-9710
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL39972617374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide