Provider Demographics
NPI:1679877526
Name:LEONARD, NINA COLEMAN (CPNP-PC, PMHCNS-BC)
Entity type:Individual
Prefix:MRS
First Name:NINA
Middle Name:COLEMAN
Last Name:LEONARD
Suffix:
Gender:F
Credentials:CPNP-PC, PMHCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 LAKESHORE DR STE B
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3875
Mailing Address - Country:US
Mailing Address - Phone:912-882-3800
Mailing Address - Fax:912-882-3303
Practice Address - Street 1:102 LAKESHORE DR STE B
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3875
Practice Address - Country:US
Practice Address - Phone:912-882-3800
Practice Address - Fax:912-882-3303
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-07
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN044413363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133857BMedicaid
GA003133857AMedicaid