1336318583 NPI number — MS. VALERIE DIANNE LEITKO

Table of content: MS. VALERIE DIANNE LEITKO (NPI 1336318583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336318583 NPI number — MS. VALERIE DIANNE LEITKO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEITKO
Provider First Name:
VALERIE
Provider Middle Name:
DIANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FYFE
Provider Other First Name:
VALERIE
Provider Other Middle Name:
DIANNE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1336318583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
680 S ROCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89502-4113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-284-3386
Provider Business Mailing Address Fax Number:
775-284-3389

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5975 S LOS ALTOS PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARKS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89436-7699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-204-4000
Provider Business Practice Location Address Fax Number:
775-204-4001
Provider Enumeration Date:
02/21/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA1097 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)