Provider Demographics
NPI:1346569035
Name:FOGLE, LEAH D (CRNA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:D
Last Name:FOGLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:C
Other - Last Name:DEANHARDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:827 W. PONCE DE LEON AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2859
Mailing Address - Country:US
Mailing Address - Phone:770-478-9877
Mailing Address - Fax:770-478-2908
Practice Address - Street 1:1984 PEACHTREE RD. NW
Practice Address - Street 2:STE. 515
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2010-05-20
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN210086367500000X
AL1-114291367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA822663026AMedicaid