Provider Demographics
NPI:1528177383
Name:WORSHAM, LEANNA JO (NP)
Entity type:Individual
Prefix:
First Name:LEANNA
Middle Name:JO
Last Name:WORSHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1225
Mailing Address - Fax:704-384-1226
Practice Address - Street 1:8310 UNIVERSITY EXEC PARK DR
Practice Address - Street 2:SUITE 550
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1572
Practice Address - Country:US
Practice Address - Phone:704-384-1225
Practice Address - Fax:704-384-1226
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5002176363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2020Medicaid
P00918719OtherRAILROAD MEDICARE
NC7003867Medicaid
NC7003867Medicaid
NCNC6968AMedicare PIN
SCNP2020Medicaid