Provider Demographics
NPI:1346951233
Name:LEISE, JODY (APRN, CNS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:LEISE
Suffix:
Gender:F
Credentials:APRN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 SOUTHVIEW RDG
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-7160
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 W GRANT ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1143
Practice Address - Country:US
Practice Address - Phone:651-345-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-12
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health