Provider Demographics
NPI:1669817201
Name:SEALY, LESA ROMONA
Entity Type:Individual
Prefix:MISS
First Name:LESA
Middle Name:ROMONA
Last Name:SEALY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LESA
Other - Middle Name:ROMONA
Other - Last Name:NORIEGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ADULT CARE PROVIDER
Mailing Address - Street 1:15 MADRE DE DIOS ST
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-4254
Mailing Address - Country:US
Mailing Address - Phone:941-629-4934
Mailing Address - Fax:941-629-4934
Practice Address - Street 1:15 MADRE DE DIOS ST
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-4254
Practice Address - Country:US
Practice Address - Phone:941-629-4934
Practice Address - Fax:941-629-4934
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906321311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001064300Medicaid