Healthcare Provider Details

I. General information

NPI: 1679147961
Provider Name (Legal Business Name): ANDREA JEAN LEBLANC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA GRIFFIN

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

147 SADLER LN
WILLISTON VT
05495-7847
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2415
  • Fax:
Mailing address:
  • Phone: 802-598-2137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number135-0000065
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: