Provider Demographics
NPI:1003436056
Name:DE LEON, AUDREY NICOLE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:NICOLE
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 1:1041 FLOR DE VALLE DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78520-9215
Mailing Address - Country:US
Mailing Address - Phone:956-346-3358
Mailing Address - Fax:
Practice Address - Street 1:105 E ALTON GLOOR BLVD
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3391
Practice Address - Country:US
Practice Address - Phone:956-831-8338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist