Healthcare Provider Details

I. General information

NPI: 1073585758
Provider Name (Legal Business Name): LEANNE TAWODA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E SHOW LOW LAKE RD
SHOW LOW AZ
85901-7881
US

IV. Provider business mailing address

PO BOX 3424
PINETOP AZ
85935-3424
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-4375
  • Fax: 928-537-2466
Mailing address:
  • Phone: 928-537-4709
  • Fax: 928-537-2466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN044839
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: