Provider Demographics
NPI:1508863325
Name:LEBLANC, ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9117 JEFFERY RD
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-4120
Mailing Address - Country:US
Mailing Address - Phone:703-966-5704
Mailing Address - Fax:
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:STE 1550
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-220-1333
Practice Address - Fax:301-220-1533
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR150538174400000X
MDAC000200367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD000822201Medicaid