Provider Demographics
NPI:1518235852
Name:BALLESTEROS, LETICIA H (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:H
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S CESAR CHAVEZ AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78839-4200
Mailing Address - Country:US
Mailing Address - Phone:830-374-2301
Mailing Address - Fax:830-374-9368
Practice Address - Street 1:308 S CESAR CHAVEZ AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78839-4200
Practice Address - Country:US
Practice Address - Phone:830-374-2301
Practice Address - Fax:830-374-9368
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX646685363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily