MEDICARE: MISS MA CORNELIA VILLAVICENCIO LEANO 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	363LA2200X	Adult Health Nurse Practitioner	LEAN-18CO92	NC
2	363LG0600X	Gerontology Nurse Practitioner	LEAN-18CO92	NC

General Provider Information

NPI Number	:	1780179580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MA CORNELIA VILLAVICENCIO LEANO NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	3081 STONE CARRIAGE CIR APT Z
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-5591
Country	:	US
Telephone Number	:	818-675-0386
Fax Number	:

Provider Business Practice Location Address
First Line	:	3081 STONE CARRIAGE CIR APT Z
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304
Country	:	US
Telephone Number	:	818-675-0386
Fax Number	:

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

Provider Enumeration Date	:	06/25/2018
Last Update Date	:	07/11/2018

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