Provider Demographics
NPI:1154183838
Name:LEONARD, GENCIE LAMONT
Entity type:Individual
Prefix:
First Name:GENCIE
Middle Name:LAMONT
Last Name:LEONARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HAVEN FOR HOPE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-1266
Mailing Address - Country:US
Mailing Address - Phone:210-220-2330
Mailing Address - Fax:
Practice Address - Street 1:1 HAVEN FOR HOPE WAY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-1266
Practice Address - Country:US
Practice Address - Phone:210-220-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX941802163W00000X
TX1156510363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse