=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932594462
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE CASIPLE CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2015
-----------------------------------------------------
Last Update Date | 04/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1108 ROSS CLARK CIR
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36301-3022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-793-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 JENKS CIR
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-522-8165
-----------------------------------------------------
Fax | 850-522-8165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 105091
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------