Provider Demographics
NPI:1912259656
Name:BERTHIAUME, LEAH DAWN (RN)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:DAWN
Last Name:BERTHIAUME
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 ANTHONY LANE S
Mailing Address - Street 2:STE 311
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418
Mailing Address - Country:US
Mailing Address - Phone:612-789-0049
Mailing Address - Fax:651-234-0864
Practice Address - Street 1:2817 ANTHONY LANE S
Practice Address - Street 2:STE 311
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418
Practice Address - Country:US
Practice Address - Phone:612-789-0049
Practice Address - Fax:651-234-0864
Is Sole Proprietor?:No
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR186580-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse