Provider Demographics
NPI:1225269939
Name:THERIAULT, LEAH JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:JEAN
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:JEAN
Other - Last Name:SOVIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:TREASURE ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33706-3050
Mailing Address - Country:US
Mailing Address - Phone:772-708-4310
Mailing Address - Fax:
Practice Address - Street 1:819 HARBOR IS
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33767-1807
Practice Address - Country:US
Practice Address - Phone:772-708-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN579293163W00000X
FLARNP9307894367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG00KROtherBCBS OF FL
FL002866300Medicaid
FLDH280WOtherTAMPA
FLG00KROtherBCBS OF FL
FLDH280SMedicare PIN
FLDH280ZMedicare PIN