Provider Demographics
NPI:1588833958
Name:BOUDREAU, LEIANE MOORE (ARNP)
Entity Type:Individual
Prefix:
First Name:LEIANE
Middle Name:MOORE
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LEIANE
Other - Middle Name:C
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S
Mailing Address - Street 2:SUITE 106A
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-460-9191
Mailing Address - Fax:904-471-4859
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 106A
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-460-9191
Practice Address - Fax:904-471-4859
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2514302363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner