Healthcare Provider Details

I. General information

NPI: 1831636026
Provider Name (Legal Business Name): MRS. ANNIE LAURIE LEBOUTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

1415 MAIN ST
CHARLOTTE NC
28204-3145
US

V. Phone/Fax

Practice location:
  • Phone: 704-491-1924
  • Fax:
Mailing address:
  • Phone: 225-281-7429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number113614
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: