Provider Demographics
NPI:1760212120
Name:BORK, LEAH DIANE (RN)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:DIANE
Last Name:BORK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 CENTENNIAL BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-8669
Mailing Address - Country:US
Mailing Address - Phone:719-598-4588
Mailing Address - Fax:719-594-4067
Practice Address - Street 1:3470 CENTENNIAL BLVD STE 205
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-8669
Practice Address - Country:US
Practice Address - Phone:719-598-4588
Practice Address - Fax:719-594-4067
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0102514163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice