Basic Information
| Provider Information | |||||||||
| NPI: | 1447786801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYNES | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGACNP, RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845500 | ||||||||
| FaxNumber: | 6019845503 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845500 | ||||||||
| FaxNumber: | 6019845503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 903191 | MS | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363L00000X | 903191 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | 903191 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 1-111893 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 01574210 | 05 | MS | MEDICAID |