Provider Demographics
NPI:1104399880
Name:LECLAIR, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LECLAIR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6267 DUFFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9264
Mailing Address - Country:US
Mailing Address - Phone:810-659-5525
Mailing Address - Fax:
Practice Address - Street 1:993 45TH ST
Practice Address - Street 2:
Practice Address - City:MANGONIA PARK
Practice Address - State:FL
Practice Address - Zip Code:33407-2413
Practice Address - Country:US
Practice Address - Phone:561-257-3348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-06
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704220646363LF0000X, 363L00000X
FLAPRN11014812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty