Provider Demographics
NPI:1689937021
Name:BAGWELL, LEAH (CRNA)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:BAGWELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:F
Other - Last Name:WINDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1427
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35502-1427
Mailing Address - Country:US
Mailing Address - Phone:334-386-2051
Mailing Address - Fax:
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8907
Practice Address - Country:US
Practice Address - Phone:205-387-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-097412367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered