Provider Demographics
NPI:1407689862
Name:LEAKE, GWEN ELIZABETH
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:ELIZABETH
Last Name:LEAKE
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 1:425 N BROWN ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-3260
Mailing Address - Country:US
Mailing Address - Phone:918-367-8316
Mailing Address - Fax:
Practice Address - Street 1:425 N BROWN ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-3260
Practice Address - Country:US
Practice Address - Phone:918-367-8316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKNA364SH1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolistic