MEDICARE: MRS. LESLIE A WHITE LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	024115	CT

General Provider Information

NPI Number	:	1053600221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESLIE A WHITE LPN

Provider Business Mailing Address
First Line	:	2340 NORTH AVE APT 3C
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06604-2346
Country	:	US
Telephone Number	:	203-368-9243
Fax Number	:	203-334-0175

Provider Business Practice Location Address
First Line	:	2340 NORTH AVE APT 3C
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06604-2346
Country	:	US
Telephone Number	:	203-368-9243
Fax Number	:	203-334-0175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2011
Last Update Date	:	03/28/2011

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