Provider Demographics
NPI:1780179580
Name:LEANO, MA CORNELIA VILLAVICENCIO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MISS
First Name:MA CORNELIA
Middle Name:VILLAVICENCIO
Last Name:LEANO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 STONE CARRIAGE CIR APT Z
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-5591
Mailing Address - Country:US
Mailing Address - Phone:818-675-0386
Mailing Address - Fax:
Practice Address - Street 1:3081 STONE CARRIAGE CIR APT Z
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:818-675-0386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLEAN-18CO92363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health