=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346951233
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JODY LEISE APRN, CNS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2022
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W GRANT ST
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55041-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-345-6711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2770 SOUTHVIEW RDG
-----------------------------------------------------
City | RED WING
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55066-7160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | 24
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------