Healthcare Provider Details

I. General information

NPI: 1770041873
Provider Name (Legal Business Name): KELLIE ANN LEAMAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLIE MILLER

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax: 208-367-2742
Mailing address:
  • Phone: 800-945-9877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number61010
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: