Healthcare Provider Details

I. General information

NPI: 1013262435
Provider Name (Legal Business Name): LEIGH E. WALLACE IVY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEIGH E. WALLACE CRNA

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 SAINT VINCENTS DR
BIRMINGHAM AL
35205-1601
US

IV. Provider business mailing address

PO BOX 55310
BIRMINGHAM AL
35255-5310
US

V. Phone/Fax

Practice location:
  • Phone: 205-939-7143
  • Fax:
Mailing address:
  • Phone: 205-731-9701
  • Fax: 205-297-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-093252
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: