Basic Information
| Provider Information | |||||||||
| NPI: | 1346569035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOGLE | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEANHARDT | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | C | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 827 W. PONCE DE LEON AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300302859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704789877 | ||||||||
| FaxNumber: | 7704782908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1984 PEACHTREE RD. NW | ||||||||
| Address2: | STE. 515 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2010 | ||||||||
| LastUpdateDate: | 08/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN210086 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 1-114291 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 822663026A | 05 | GA | MEDICAID |