Provider Demographics
NPI:1053428417
Name:NITKE, LEAH A (DO)
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:A
Last Name:NITKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:ANN
Other - Last Name:KORNOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:#130
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54308-8900
Practice Address - Country:US
Practice Address - Phone:920-288-8100
Practice Address - Fax:920-288-8152
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47005207R00000X
IL36109515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43515600Medicaid