Basic Information
| Provider Information | |||||||||
| NPI: | 1467929661 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESERRA | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4331 W ANDREW JOHNSON HWY | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378141036 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4331 W ANDREW JOHNSON HWY | ||||||||
| Address2: | |||||||||
| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378141036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232546672 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2018 | ||||||||
| LastUpdateDate: | 03/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | E-15770 | MS | N | Pharmacy Service Providers | Pharmacist | 183500000X | 42138 | TN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.