MEDICARE: MS. JO ANNA DOMIANO LEBLANC NURSE PRACTITIONER

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	363LW0102X	Women's Health Nurse Practitioner	RN045561 AP02308	LA

General Provider Information

NPI Number	:	1730178492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JO ANNA DOMIANO LEBLANC NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	607 FAIRVIEW DR
Second Line	:
City	:	BERWICK
State	:	LA
Zip	:	70342-2084
Country	:	US
Telephone Number	:	985-385-4357
Fax Number	:

Provider Business Practice Location Address
First Line	:	1200 DAVID DR
Second Line	:
City	:	MORGAN CITY
State	:	LA
Zip	:	70380-1362
Country	:	US
Telephone Number	:	985-380-2441
Fax Number	:	985-380-2489

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	11/21/2014

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