Healthcare Provider Details

I. General information

NPI: 1114275336
Provider Name (Legal Business Name): LEILANI ANN RODRIGUEZ NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 E CLINTON AVE
FRESNO CA
93703-2223
US

IV. Provider business mailing address

4747 N BARTON AVE
FRESNO CA
93726-1119
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-6100
  • Fax:
Mailing address:
  • Phone: 559-223-6969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number495309
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95005434
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: