Provider Demographics
NPI:1154742187
Name:DE LEON, JANICE
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:DE LEON
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 1:20 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4735
Mailing Address - Country:US
Mailing Address - Phone:203-848-0486
Mailing Address - Fax:
Practice Address - Street 1:400 CAPITAL BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3576
Practice Address - Country:US
Practice Address - Phone:203-848-0486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005543363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health