Provider Demographics
NPI:1003874629
Name:LEONARD, CHARLES KENNETH (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KENNETH
Last Name:LEONARD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:MABTON
Mailing Address - State:WA
Mailing Address - Zip Code:98935
Mailing Address - Country:US
Mailing Address - Phone:509-894-5559
Mailing Address - Fax:309-403-8642
Practice Address - Street 1:1016 TACOMA AVE
Practice Address - Street 2:SUNNYSIDE COMMUNITY HOSPITAL
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2263
Practice Address - Country:US
Practice Address - Phone:509-837-1500
Practice Address - Fax:509-837-1584
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA38956367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
43762OtherL & I
WA9606591Medicaid
WA9606591Medicaid