Healthcare Provider Details

I. General information

NPI: 1679589758
Provider Name (Legal Business Name): LAURA M LEBLANC C-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA M. CICCONETTI C-FNP

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4705 MONTGOMERY BLVD NE SUITE 102
ALBUQUERQUE NM
87109-1226
US

IV. Provider business mailing address

4001 INDIAN SCHOOL RD NE SUITE 325
ALBUQUERQUE NM
87110-3816
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-7833
  • Fax: 505-727-6944
Mailing address:
  • Phone: 505-727-5785
  • Fax: 505-727-9770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR24443
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: