MEDICARE: MRS. LISA ELAINE LEQUEUX

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	174400000X	Specialist

General Provider Information

NPI Number	:	1538729207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA ELAINE LEQUEUX

Provider Business Mailing Address
First Line	:	3859 MAPLETON RD
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-9509
Country	:	US
Telephone Number	:	716-807-5258
Fax Number	:

Provider Business Practice Location Address
First Line	:	3859 MAPLETON RD
Second Line	:
City	:	NORTH TONAWANDA
State	:	NY
Zip	:	14120-9509
Country	:	US
Telephone Number	:	716-807-5258
Fax Number	:

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

Provider Enumeration Date	:	06/15/2019
Last Update Date	:	06/15/2019

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