Provider Demographics
NPI:1619005600
Name:LEBRETON, LAURENCE LISA (DOM)
Entity Type:Individual
Prefix:DR
First Name:LAURENCE
Middle Name:LISA
Last Name:LEBRETON
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 MONTEZUMA AVE # 393
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2626
Mailing Address - Country:US
Mailing Address - Phone:505-577-7855
Mailing Address - Fax:
Practice Address - Street 1:509 CAMINO DE LOS MARQUEZ
Practice Address - Street 2:SUITE 1
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1831
Practice Address - Country:US
Practice Address - Phone:505-577-7855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM790171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist