Provider Demographics
NPI:1962974279
Name:DINGLEDINE, JALEEN MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:JALEEN
Middle Name:MARIE
Last Name:DINGLEDINE
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 1:20 FULTON ST E APT 1102
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5266
Mailing Address - Country:US
Mailing Address - Phone:231-286-9419
Mailing Address - Fax:
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-852-5851
Practice Address - Fax:502-852-3762
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014348367500000X
MI4704320678367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100658510Medicaid
IN300037165Medicaid