Provider Demographics
NPI:1043899099
Name:BOOTH, LEESA SIMANTON (DNP)
Entity type:Individual
Prefix:DR
First Name:LEESA
Middle Name:SIMANTON
Last Name:BOOTH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CALLE DE LAS ROSAS
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-8001
Mailing Address - Country:US
Mailing Address - Phone:760-578-3601
Mailing Address - Fax:
Practice Address - Street 1:119 CALLE DE LAS ROSAS
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-8001
Practice Address - Country:US
Practice Address - Phone:760-578-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95014445363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANPLICENSEOtherDO NOT HAVE