Provider Demographics
NPI:1023398476
Name:LEISECA, LAURA M
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:M
Last Name:LEISECA
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 1:8015 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3437
Mailing Address - Country:US
Mailing Address - Phone:305-494-5280
Mailing Address - Fax:
Practice Address - Street 1:8015 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3437
Practice Address - Country:US
Practice Address - Phone:305-494-5280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist