Basic Information
| Provider Information | |||||||||
| NPI: | 1215418918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAF | ||||||||
| FirstName: | JESSE | ||||||||
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| Credential: | RN BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 E 11TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820015496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072751901 | ||||||||
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| Practice Location | |||||||||
| Address1: | 214 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076342273 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WN0800X | 39725 | WY | Y | Nursing Service Providers | Registered Nurse | Neuroscience |
No ID Information.