Provider Demographics
NPI:1841019346
Name:LEAVELL, JEREMY DERRELL (DNP APRN CRNA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DERRELL
Last Name:LEAVELL
Suffix:
Gender:M
Credentials:DNP APRN CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-6512
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2595
Practice Address - Country:US
Practice Address - Phone:651-254-6512
Practice Address - Fax:651-254-3048
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN3041367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered