Provider Demographics
NPI:1114161239
Name:LEBOO, AUDRA A (MBCHB)
Entity Type:Individual
Prefix:DR
First Name:AUDRA
Middle Name:A
Last Name:LEBOO
Suffix:
Gender:F
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1118
Mailing Address - Country:US
Mailing Address - Phone:585-637-3905
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:23 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:HONEOYE FALLS
Practice Address - State:NY
Practice Address - Zip Code:14472-1149
Practice Address - Country:US
Practice Address - Phone:585-624-2121
Practice Address - Fax:585-624-7283
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60 266255207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine