1962017673 NPI number — MRS. ELIZABETH ANNE LEUTE

Table of content: MRS. ELIZABETH ANNE LEUTE (NPI 1962017673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962017673 NPI number — MRS. ELIZABETH ANNE LEUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEUTE
Provider First Name:
ELIZABETH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
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:
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:
1962017673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11221 NORTHRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRETNA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68028-6935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-332-5578
Provider Business Mailing Address Fax Number:
402-408-2539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11221 NORTHRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRETNA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68028-6935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-332-5578
Provider Business Practice Location Address Fax Number:
402-408-2539
Provider Enumeration Date:
09/10/2020

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: 163WS0200X , with the licence number:  40144 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40144 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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