Provider Demographics
NPI:1073677126
Name:LEEDS, LORI (CRNA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:LEEDS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-2514
Mailing Address - Country:US
Mailing Address - Phone:812-996-0643
Mailing Address - Fax:812-996-0214
Practice Address - Street 1:800 W 9TH ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2514
Practice Address - Country:US
Practice Address - Phone:812-996-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28128280367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200086620Medicaid
IN000000081032OtherANTHEM BS
IN28128280OtherINDIANA LICENSE
IN200086620Medicaid
IN000000081032OtherANTHEM BS