Provider Demographics
NPI:1174367387
Name:LEGGETT, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LEGGETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:WV
Mailing Address - Zip Code:26456-2082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 GRANDE MEADOWS DR STE 203
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9035
Practice Address - Country:US
Practice Address - Phone:304-592-3538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV62065376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide