Provider Demographics
NPI:1174555064
Name:LEISURE, LYNIETA LYNN (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LYNIETA
Middle Name:LYNN
Last Name:LEISURE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-5528
Mailing Address - Country:US
Mailing Address - Phone:954-457-4333
Mailing Address - Fax:
Practice Address - Street 1:415 E HALLANDALE BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-5528
Practice Address - Country:US
Practice Address - Phone:954-457-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45086363LF0000X
FL11029666363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS110135002Medicare PIN