Basic Information
| Provider Information | |||||||||
| NPI: | 1134113301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER-LEONARD | ||||||||
| FirstName: | KIMMERLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNA,MAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2329 | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982737329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604662542 | ||||||||
| FaxNumber: | 3604662682 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 PIONEER RD | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989489606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093919434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP30002282 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 9840642 | 01 | WA | CRIME VICTIMS | OTHER | 2851MI | 01 | WA | REGENCE BLUE SHIELD | OTHER | 0184061 | 01 | WA | DEPARTMENT OF LABOR AND INDUSTRIES | OTHER | 9618109 | 05 | WA | MEDICAID |