Provider Demographics
NPI:1831636026
Name:LEBOUTON, ANNIE LAURIE
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:LAURIE
Last Name:LEBOUTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3145
Mailing Address - Country:US
Mailing Address - Phone:225-281-7429
Mailing Address - Fax:
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-491-1924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC113614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered