Healthcare Provider Details

I. General information

NPI: 1518235852
Provider Name (Legal Business Name): LETICIA H BALLESTEROS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S CESAR CHAVEZ AVE
CRYSTAL CITY TX
78839-4200
US

IV. Provider business mailing address

308 S CESAR CHAVEZ AVE
CRYSTAL CITY TX
78839-4200
US

V. Phone/Fax

Practice location:
  • Phone: 830-374-2301
  • Fax: 830-374-9368
Mailing address:
  • Phone: 830-374-2301
  • Fax: 830-374-9368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number646685
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: