Provider Demographics
NPI:1093738445
Name:LEJA, CAROLYN E (CNM)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:E
Last Name:LEJA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:E
Other - Last Name:WASHNOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE # MC020
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY635895367A00000X
PAMW010129367A00000X
MI4704245454367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03269647Medicaid
NYJ400032738Medicare PIN