Healthcare Provider Details

I. General information

NPI: 1285125039
Provider Name (Legal Business Name): LESLIE ANNE VENEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2018
Last Update Date: 05/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6730 CASCADE RD SE
GRAND RAPIDS MI
49546-8718
US

IV. Provider business mailing address

765 HAMPDEN AVE APT 136
SAINT PAUL MN
55114-1664
US

V. Phone/Fax

Practice location:
  • Phone: 949-096-0616
  • Fax:
Mailing address:
  • Phone: 616-808-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number6901011748
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: