Provider Demographics
NPI:1316363252
Name:GARCIA LEACH, GWENDOLYN DENISE (CPNP)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:DENISE
Last Name:GARCIA LEACH
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 W ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5808
Mailing Address - Country:US
Mailing Address - Phone:910-692-2444
Mailing Address - Fax:
Practice Address - Street 1:195 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5808
Practice Address - Country:US
Practice Address - Phone:910-692-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006800363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902600Medicaid