Provider Demographics
NPI:1063520005
Name:LEAVERY, MARY K (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:LEAVERY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 KIMEL PARK DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6983
Mailing Address - Country:US
Mailing Address - Phone:336-768-3212
Mailing Address - Fax:336-768-9019
Practice Address - Street 1:145 KIMEL PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-768-3212
Practice Address - Fax:336-768-9019
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC993367500000X
NC45453367500000X
NY360053-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0749Medicaid
NYRB7323Medicare PIN
R82918Medicare UPIN
SCQ31758Medicare ID - Type Unspecified