Provider Demographics
NPI:1306063565
Name:LEOFFLER, KATHLEEN C (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:C
Last Name:LEOFFLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2321
Mailing Address - Country:US
Mailing Address - Phone:770-801-2500
Mailing Address - Fax:
Practice Address - Street 1:1615 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1325
Practice Address - Country:US
Practice Address - Phone:770-252-6767
Practice Address - Fax:770-252-0021
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN143499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBLMHMedicare PIN