1518243187 NPI number — CANESSA CRAIGO LEEFLANG FNP

Table of content: CANESSA CRAIGO LEEFLANG FNP (NPI 1518243187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518243187 NPI number — CANESSA CRAIGO LEEFLANG FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEEFLANG
Provider First Name:
CANESSA
Provider Middle Name:
CRAIGO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRAIGO
Provider Other First Name:
CANESSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518243187
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12272 S 800 E
Provider Second Line Business Mailing Address:
STE A
Provider Business Mailing Address City Name:
DRAPER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84020-9789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-523-1300
Provider Business Mailing Address Fax Number:
801-523-1301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12272 S 800 E
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-9789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-523-1300
Provider Business Practice Location Address Fax Number:
801-523-1301
Provider Enumeration Date:
10/27/2011

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: 363LP0200X , with the licence number:  59947704405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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