Provider Demographics
NPI:1356057707
Name:LEAVELL, JALYSSA
Entity type:Individual
Prefix:
First Name:JALYSSA
Middle Name:
Last Name:LEAVELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-2220 KAIWAWALO ST UNIT 303
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-6547
Mailing Address - Country:US
Mailing Address - Phone:803-727-9899
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant