Healthcare Provider Details

I. General information

NPI: 1891019980
Provider Name (Legal Business Name): LEANNA MAYNARD LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

942 S ATLANTIC BLVD
LOS ANGELES CA
90022-4004
US

IV. Provider business mailing address

2308 HIGHLAND DR
LOS ANGELES CA
90016-2218
US

V. Phone/Fax

Practice location:
  • Phone: 323-261-9700
  • Fax: 323-263-8042
Mailing address:
  • Phone: 323-263-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN 91681
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: