Provider Demographics
NPI:1659584001
Name:LEBORD, JOHNNY LEE (MP)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:LEE
Last Name:LEBORD
Suffix:
Gender:M
Credentials:MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15539 MERIDIAN AVE N
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-6038
Mailing Address - Country:US
Mailing Address - Phone:206-755-0008
Mailing Address - Fax:206-933-6088
Practice Address - Street 1:9001 35TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3820
Practice Address - Country:US
Practice Address - Phone:206-755-0008
Practice Address - Fax:206-933-6088
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015163174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist