Healthcare Provider Details

I. General information

NPI: 1750675732
Provider Name (Legal Business Name): MAUREEN RITA LEATHERSICH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAUREEN RITA LAMOREAUX

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BETHEL DR # 7
LIMA NY
14485-9757
US

IV. Provider business mailing address

PO BOX 487
LIMA NY
14485-0487
US

V. Phone/Fax

Practice location:
  • Phone: 585-748-1883
  • Fax:
Mailing address:
  • Phone: 585-748-1883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number478297-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: