Provider Demographics
NPI:1316655061
Name:LEONI, WYVETTE ANGELA TRESSA MARIA (PA-C)
Entity type:Individual
Prefix:
First Name:WYVETTE
Middle Name:ANGELA TRESSA MARIA
Last Name:LEONI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4822 PARKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4629
Mailing Address - Country:US
Mailing Address - Phone:559-707-8810
Mailing Address - Fax:
Practice Address - Street 1:710 JOHNNIE DODDS BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3045
Practice Address - Country:US
Practice Address - Phone:843-800-1303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant