Provider Demographics
NPI:1194347211
Name:LEONARD, MARTIN JAMES (RN)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:JAMES
Last Name:LEONARD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1866
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-5666
Mailing Address - Country:US
Mailing Address - Phone:248-472-9698
Mailing Address - Fax:248-587-8698
Practice Address - Street 1:3067 BEACH LAKE DR E
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48380-2864
Practice Address - Country:US
Practice Address - Phone:248-684-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704136900163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management