Provider Demographics
NPI:1043555287
Name:FYVIE, LEANN
Entity type:Individual
Prefix:MRS
First Name:LEANN
Middle Name:
Last Name:FYVIE
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 1:221 WHITETAIL CT
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3040
Mailing Address - Country:US
Mailing Address - Phone:518-863-6523
Mailing Address - Fax:
Practice Address - Street 1:623 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4031
Practice Address - Country:US
Practice Address - Phone:518-782-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY690460121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist