MEDICARE: THERESA LYNETTE LEBLANC RN

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	163WH0200X	Home Health Registered Nurse	RN121159	LA
2	163WH0200X	Home Health Registered Nurse	121159	LA

General Provider Information

NPI Number	:	1912408873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA LYNETTE LEBLANC RN

Provider Business Mailing Address
First Line	:	3330 FANNIN ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-3801
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5172 ROCK DR
Second Line	:
City	:	SULPHUR
State	:	LA
Zip	:	70665-9220
Country	:	US
Telephone Number	:	337-794-1810
Fax Number	:

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

Provider Enumeration Date	:	02/26/2018
Last Update Date	:	03/17/2018

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