Basic Information
Provider Information | |||||||||
NPI: | 1346581121 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEGGETT | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 159 JENNA LN | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | GA | ||||||||
PostalCode: | 301576992 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706569421 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11975 MORRIS RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ALPHARETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300054419 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707513600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2013 | ||||||||
LastUpdateDate: | 03/04/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | CNM1346 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
No ID Information.