Provider Demographics
NPI:1235129610
Name:HERBERT, LEILANI CALICA (CRNA)
Entity type:Individual
Prefix:
First Name:LEILANI
Middle Name:CALICA
Last Name:HERBERT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LEILANI
Other - Middle Name:
Other - Last Name:CALICA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 29TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1401
Mailing Address - Country:US
Mailing Address - Phone:615-327-4304
Mailing Address - Fax:
Practice Address - Street 1:110 29TH AVE N STE 202
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1448
Practice Address - Country:US
Practice Address - Phone:615-327-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX600584207L00000X
TN50592367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002932402Medicaid
TX050592OtherRECERTIFICATION
TN4133317OtherBCBS OF TN
TX82960UOtherBLUE CROSS BLUE SHIELD
TN3636554Medicaid
TX430068752OtherRAILROAD MEDICARE
KY74012055Medicaid
AL9938554Medicaid
AL9938554Medicaid
TN3636554Medicare PIN
TX050592OtherRECERTIFICATION