Provider Demographics
NPI:1306442454
Name:LEAVITT, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 GENERAL BOOTH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5692
Mailing Address - Country:US
Mailing Address - Phone:757-426-6973
Mailing Address - Fax:757-426-6976
Practice Address - Street 1:1615 GENERAL BOOTH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5692
Practice Address - Country:US
Practice Address - Phone:757-426-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02020063051835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care