Provider Demographics
NPI:1962933101
Name:LEAHY, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:LEAHY
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-482-7800
Practice Address - Fax:207-482-7898
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD91549207LC0200X
MEMD26960207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1962933101Medicaid