1407845647 NPI number — MRS. TRACEY PAULSON LEEDOM MS

Table of content: MRS. TRACEY PAULSON LEEDOM MS (NPI 1407845647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407845647 NPI number — MRS. TRACEY PAULSON LEEDOM MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEEDOM
Provider First Name:
TRACEY
Provider Middle Name:
PAULSON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407845647
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3407 FOREST GROVE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27703-9104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-596-1931
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
DUKE SOUTH CLINIC BUILDING 3828A RED ZONE
Provider Second Line Business Practice Location Address:
BOX 2974
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27710-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-684-3181
Provider Business Practice Location Address Fax Number:
919-668-6119
Provider Enumeration Date:
10/20/2005

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: 170300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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