Provider Demographics
NPI:1992155840
Name:STREETER, LEESA (RN)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:
Last Name:STREETER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080-9736
Mailing Address - Country:US
Mailing Address - Phone:315-395-8039
Mailing Address - Fax:
Practice Address - Street 1:46 N MAIN ST
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:NY
Practice Address - Zip Code:13080-9736
Practice Address - Country:US
Practice Address - Phone:315-395-8039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY660476163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse