Healthcare Provider Details

I. General information

NPI: 1023398476
Provider Name (Legal Business Name): MS. LAURA M LEISECA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 W 14TH AVE
HIALEAH FL
33014-3437
US

IV. Provider business mailing address

8015 W 14TH AVE
HIALEAH FL
33014-3437
US

V. Phone/Fax

Practice location:
  • Phone: 305-494-5280
  • Fax:
Mailing address:
  • Phone: 305-494-5280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: