Provider Demographics
NPI:1861693640
Name:BLANCHARD, LEISA DAWN (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:LEISA
Middle Name:DAWN
Last Name:BLANCHARD
Suffix:
Gender:F
Credentials:FNP-C
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 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1307 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCKWOOD
Practice Address - State:MO
Practice Address - Zip Code:65682-8327
Practice Address - Country:US
Practice Address - Phone:417-232-4560
Practice Address - Fax:417-232-4611
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142484163WD0400X
MO2015034072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO359160504Medicaid
MO1861693640Medicaid
MO359160504Medicaid