Basic Information
| Provider Information | |||||||||
| NPI: | 1891721437 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEYBA | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E ROUTT AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810032916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 119829 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 364SF0001X | APN.0990713-NP | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
| ID | Type | State | Issuer | Description | 02455340 | 05 | CO | MEDICAID | 311836YLQP | 01 | CO | MEDICARE PTAN | OTHER |