Provider Demographics
NPI:1679589758
Name:LEBLANC, LAURA M (C-FNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:CICCONETTI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:C-FNP
Mailing Address - Street 1:4001 INDIAN SCHOOL RD NE
Mailing Address - Street 2:SUITE 325
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3816
Mailing Address - Country:US
Mailing Address - Phone:505-727-5785
Mailing Address - Fax:505-727-9770
Practice Address - Street 1:4705 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1226
Practice Address - Country:US
Practice Address - Phone:505-727-7833
Practice Address - Fax:505-727-6944
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR24443363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11336056Medicaid
AZ888042Medicaid
NMA17756OtherPRONET/AETNA
NM201049006Medicaid
NMNM006A18OtherBCBS
NMQ22744Medicare UPIN
AZ888042Medicaid
NM343425701Medicare ID - Type UnspecifiedMEDICARE