=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316412042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE ALICIA LEONHARDT FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2018
-----------------------------------------------------
Last Update Date | 06/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6516 EVERGREEN AVE
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79707-9636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-312-8150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6516 EVERGREEN AVE
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79707-9636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 432-312-8150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 818884
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP139768
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------