Provider Demographics
NPI:1356794721
Name:LIENESCH, KEVIN (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LIENESCH
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-0267
Mailing Address - Country:US
Mailing Address - Phone:206-321-6509
Mailing Address - Fax:
Practice Address - Street 1:701 LEWISTON ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:ID
Practice Address - Zip Code:83522-9750
Practice Address - Country:US
Practice Address - Phone:208-962-3251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT143767367500000X
WAAP60678113367500000X
ID59906367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered