Provider Demographics
NPI:1447711122
Name:STAFFORD, LEAH ANN (PT ASSISTANT)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:ANN
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:PT ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:CA
Mailing Address - Zip Code:95669-0725
Mailing Address - Country:US
Mailing Address - Phone:209-245-3606
Mailing Address - Fax:
Practice Address - Street 1:813 COURT ST STE 2
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2169
Practice Address - Country:US
Practice Address - Phone:209-223-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT-5069208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation