Provider Demographics
NPI:1932326741
Name:LEISSRING, TERRYLYNN
Entity type:Individual
Prefix:MRS
First Name:TERRYLYNN
Middle Name:
Last Name:LEISSRING
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 1:2805 W OLD HIGHWAY 91
Mailing Address - Street 2:
Mailing Address - City:INKOM
Mailing Address - State:ID
Mailing Address - Zip Code:83245-1601
Mailing Address - Country:US
Mailing Address - Phone:208-775-3097
Mailing Address - Fax:208-775-3097
Practice Address - Street 1:2805 W OLD HIGHWAY 91
Practice Address - Street 2:
Practice Address - City:INKOM
Practice Address - State:ID
Practice Address - Zip Code:83245-1601
Practice Address - Country:US
Practice Address - Phone:208-775-3097
Practice Address - Fax:208-775-3097
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDW36708251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management