Healthcare Provider Details

I. General information

NPI: 1306393145
Provider Name (Legal Business Name): LAUREN LEEFLANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

356 E MIDWAY RD
FORT PIERCE FL
34982-7148
US

IV. Provider business mailing address

356 E MIDWAY RD
FORT PIERCE FL
34982-7148
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-9746
  • Fax:
Mailing address:
  • Phone: 772-464-9746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9109766
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: