=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366576852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENE' LEE LANDRY RN BSN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 29.5 ROAD
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81504-5033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-248-6912
-----------------------------------------------------
Fax | 970-248-6972
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 836 CATALINA CT
-----------------------------------------------------
City | GRAND JUNCTION
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81506-1794
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-245-8569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | 101316
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------