Provider Demographics
NPI:1831440692
Name:LEONARD, KERISTEN
Entity type:Individual
Prefix:
First Name:KERISTEN
Middle Name:
Last Name:LEONARD
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 1:1813 4TH AVE
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-2728
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 WOLF RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6007
Practice Address - Country:US
Practice Address - Phone:518-437-0152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300284164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse