Basic Information
| Provider Information | |||||||||
| NPI: | 1619580420 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEAUDRIE | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23798 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405233798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681030 | ||||||||
| FaxNumber: | 8592694120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 LONE OAK RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704442444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 3015010 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3015010 | 01 | KY | KENTUCKY CRNA LICENSE | OTHER |