Provider Demographics
NPI:1750999512
Name:LEIWALO, VIMARYS (DNP, CRNA)
Entity type:Individual
Prefix:
First Name:VIMARYS
Middle Name:
Last Name:LEIWALO
Suffix:
Gender:
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:VIMARYS
Other - Middle Name:
Other - Last Name:COLON-SOTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2817 ROCK MERRITT AVENUE WOMACK ARMY MEDICAL CENTER
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 ROCK MERRITT AVENUE WOMACK ARMY MEDICAL CENTER
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:910-907-6069
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX782472367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered