Provider Demographics
NPI:1144903964
Name:LEBLANC, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17177 N LAUREL PARK DR STE 439
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3938
Mailing Address - Country:US
Mailing Address - Phone:734-462-0340
Mailing Address - Fax:734-462-0344
Practice Address - Street 1:768 YORK ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1483
Practice Address - Country:US
Practice Address - Phone:810-287-1488
Practice Address - Fax:734-462-0344
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259696363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily