Healthcare Provider Details

I. General information

NPI: 1407594567
Provider Name (Legal Business Name): MEREDITH LOU VAN LEER LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 RAILROAD ST
BROOKINGS OR
97415
US

IV. Provider business mailing address

PO BOX 634
BROOKINGS OR
97415-0003
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-1152
  • Fax:
Mailing address:
  • Phone: 541-412-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN226461
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number226461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: