Provider Demographics
NPI:1366796468
Name:BOOTHE, LEONIE EVADNEY (CNA)
Entity type:Individual
Prefix:
First Name:LEONIE
Middle Name:EVADNEY
Last Name:BOOTHE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 NE 110 STREET
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161
Mailing Address - Country:US
Mailing Address - Phone:305-947-1439
Mailing Address - Fax:305-947-1439
Practice Address - Street 1:80 NE 166 STREET
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33162
Practice Address - Country:US
Practice Address - Phone:305-947-1439
Practice Address - Fax:305-947-1439
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA82954251E00000X
FLA9211310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141080600Medicaid