Basic Information
| Provider Information | |||||||||
| NPI: | 1447382809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LECORNU | ||||||||
| FirstName: | ANDRE | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LECORNU | ||||||||
| OtherFirstName: | ANDRE | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2960 TONGASS AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284902 | ||||||||
| FaxNumber: | 9072285256 | ||||||||
| Practice Location | |||||||||
| Address1: | 2960 TONGASS AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | KETCHIKAN | ||||||||
| State: | AK | ||||||||
| PostalCode: | 999015742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072284902 | ||||||||
| FaxNumber: | 9072285256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 9976 | AK | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 9976 | 01 | AK | LICENSED REGISTERED NURSE | OTHER |