Healthcare Provider Details

I. General information

NPI: 1710375613
Provider Name (Legal Business Name): LESLIE URBANCZYK R.N.FA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 GASTON AVE SUITE 350
DALLAS TX
75214-3922
US

IV. Provider business mailing address

5909 LUTHER LN
DALLAS TX
75225-5915
US

V. Phone/Fax

Practice location:
  • Phone: 972-707-0396
  • Fax:
Mailing address:
  • Phone: 806-674-0932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number559058
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: