Provider Demographics
NPI:1194991893
Name:RONNEBERG, LESLIE A (LPN)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:A
Last Name:RONNEBERG
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:38933 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:MENAHGA
Mailing Address - State:MN
Mailing Address - Zip Code:56464
Mailing Address - Country:US
Mailing Address - Phone:218-564-4848
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0567242164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse