Provider Demographics
NPI:1134113301
Name:MILLER-LEONARD, KIMMERLE (CRNA,MAE)
Entity Type:Individual
Prefix:MRS
First Name:KIMMERLE
Middle Name:
Last Name:MILLER-LEONARD
Suffix:
Gender:F
Credentials:CRNA,MAE
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 2329
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-7329
Mailing Address - Country:US
Mailing Address - Phone:360-466-2542
Mailing Address - Fax:360-466-2682
Practice Address - Street 1:1030 PIONEER RD
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-9606
Practice Address - Country:US
Practice Address - Phone:509-391-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002282367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9840642OtherCRIME VICTIMS
WA2851MIOtherREGENCE BLUE SHIELD
WA0184061OtherDEPARTMENT OF LABOR AND INDUSTRIES
WA9618109Medicaid
WA9840642OtherCRIME VICTIMS