Provider Demographics
NPI:1447382809
Name:LECORNU, ANDRE M (RN)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:M
Last Name:LECORNU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:ANDRE
Other - Middle Name:M
Other - Last Name:LECORNU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:2960 TONGASS AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-5742
Mailing Address - Country:US
Mailing Address - Phone:907-228-4902
Mailing Address - Fax:907-228-5256
Practice Address - Street 1:2960 TONGASS AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5742
Practice Address - Country:US
Practice Address - Phone:907-228-4902
Practice Address - Fax:907-228-5256
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK9976163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK9976OtherLICENSED REGISTERED NURSE