Healthcare Provider Details

I. General information

NPI: 1477971489
Provider Name (Legal Business Name): LEAH RENEE MOREAU AGACNP, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 METROPOLITAN DR SUITE 210
BEAUMONT TX
77706-2407
US

IV. Provider business mailing address

6025 METROPOLITAN DR SUITE 210
BEAUMONT TX
77706-2407
US

V. Phone/Fax

Practice location:
  • Phone: 409-833-2225
  • Fax:
Mailing address:
  • Phone: 409-833-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP125459
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number768819
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: