Provider Demographics
NPI:1285125039
Name:VENEMAN, LESLIE ANNE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:VENEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 HAMPDEN AVE APT 136
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1664
Mailing Address - Country:US
Mailing Address - Phone:616-808-1175
Mailing Address - Fax:
Practice Address - Street 1:6730 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8718
Practice Address - Country:US
Practice Address - Phone:949-096-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2018-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6901011748390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program