Provider Demographics
NPI:1588244404
Name:LEAKE, SAMANTHA KATELYN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:KATELYN
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 1:313 LYNNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3911
Mailing Address - Country:US
Mailing Address - Phone:770-596-1301
Mailing Address - Fax:
Practice Address - Street 1:313 LYNNWOOD DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3911
Practice Address - Country:US
Practice Address - Phone:770-596-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN279271163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse