Provider Demographics
NPI:1023850690
Name:GAISTHIA, LEANNA M (COMMUNITY HEALTH WOR)
Entity type:Individual
Prefix:
First Name:LEANNA
Middle Name:M
Last Name:GAISTHIA
Suffix:
Gender:F
Credentials:COMMUNITY HEALTH WOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020
Mailing Address - Country:US
Mailing Address - Phone:505-287-6500
Mailing Address - Fax:505-287-5393
Practice Address - Street 1:1423 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020
Practice Address - Country:US
Practice Address - Phone:505-287-6500
Practice Address - Fax:505-287-5393
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMS1-15023172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker