Provider Demographics
NPI:1043708118
Name:ETIENNE, LEARO
Entity Type:Individual
Prefix:MR
First Name:LEARO
Middle Name:
Last Name:ETIENNE
Suffix:
Gender:M
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 2219
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-6219
Mailing Address - Country:US
Mailing Address - Phone:863-412-9775
Mailing Address - Fax:863-582-9918
Practice Address - Street 1:3404 AVENUE X NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-1053
Practice Address - Country:US
Practice Address - Phone:863-412-9775
Practice Address - Fax:863-582-9918
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$OtherSOCIAL