1760615595 NPI number — SHELLEY S LEACH FNP

Table of content: SHELLEY S LEACH FNP (NPI 1760615595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760615595 NPI number — SHELLEY S LEACH FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEACH
Provider First Name:
SHELLEY
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760615595
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1842 SIMPSON HIGHWAY 149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDENHALL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39114-3438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-847-7130
Provider Business Mailing Address Fax Number:
601-847-7130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 JEFFERSON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HEBRON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-694-2116
Provider Business Practice Location Address Fax Number:
601-694-2119
Provider Enumeration Date:
08/27/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R863242 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00476391 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".