Healthcare Provider Details

I. General information

NPI: 1073677126
Provider Name (Legal Business Name): LORI LEEDS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 9TH ST
JASPER IN
47546-2514
US

IV. Provider business mailing address

800 W 9TH ST
JASPER IN
47546-2514
US

V. Phone/Fax

Practice location:
  • Phone: 812-996-2345
  • Fax:
Mailing address:
  • Phone: 812-996-0643
  • Fax: 812-996-0214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28128280
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: