Provider Demographics
NPI:1548494792
Name:DE LEON, LAURA AUTUMN
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:AUTUMN
Last Name:DE LEON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-664-2552
Mailing Address - Fax:704-664-5382
Practice Address - Street 1:133 WELTON WAY
Practice Address - Street 2:SUITE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9163
Practice Address - Country:US
Practice Address - Phone:704-664-2552
Practice Address - Fax:704-664-5382
Is Sole Proprietor?:No
Enumeration Date:2009-05-02
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006144363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner