Healthcare Provider Details

I. General information

NPI: 1366010068
Provider Name (Legal Business Name): TIFFANY T LEBLANC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8166 MAIN ST
HOUMA LA
70360-3404
US

IV. Provider business mailing address

8166 MAIN ST
HOUMA LA
70360-3404
US

V. Phone/Fax

Practice location:
  • Phone: 985-873-4141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number221498
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN152316
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: