Provider Demographics
NPI:1477129559
Name:WHEATON, LEAH ANTOINETTE
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ANTOINETTE
Last Name:WHEATON
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 1:99 CONIFER HILL DR
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-1193
Mailing Address - Country:US
Mailing Address - Phone:787-742-5559
Mailing Address - Fax:978-304-0568
Practice Address - Street 1:99 CONIFER HILL DR
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-1193
Practice Address - Country:US
Practice Address - Phone:978-774-2555
Practice Address - Fax:978-304-0568
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-31
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2322369207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAF03210630OtherAANP CERTIFICATION NUMBER