MEDICARE: MS. SHELLY M. LEITCH RN, MSN, CPNP

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	363LP0200X	Pediatric Nurse Practitioner	453991	TX

General Provider Information

NPI Number	:	1346307634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHELLY M. LEITCH RN, MSN, CPNP

Provider Business Mailing Address
First Line	:	300 SEACREST BLVD
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-9231
Country	:	US
Telephone Number	:	281-538-2722
Fax Number	:

Provider Business Practice Location Address
First Line	:	416 HIGHWAY 87
Second Line	:	TEEN HEALTH CENTER, INC.-CRENSHAW
City	:	CRYSTAL BEACH
State	:	TX
Zip	:	77650
Country	:	US
Telephone Number	:	409-766-5750
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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