Basic Information
Provider Information | |||||||||
NPI: | 1609947142 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TEW | ||||||||
FirstName: | LEANNE | ||||||||
MiddleName: | LOTT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LOTT | ||||||||
OtherFirstName: | ELAINE | ||||||||
OtherMiddleName: | LEANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNP | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 908 | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393020908 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6017034282 | ||||||||
FaxNumber: | 6017034597 | ||||||||
Practice Location | |||||||||
Address1: | 1404 E PUSHMATAHA ST | ||||||||
Address2: |   | ||||||||
City: | BUTLER | ||||||||
State: | AL | ||||||||
PostalCode: | 369042728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2054594488 | ||||||||
FaxNumber: | 2054593010 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/13/2006 | ||||||||
LastUpdateDate: | 02/17/2014 | ||||||||
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 | 363L00000X | 1075117 | AL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 891001830 | 05 | AL |   | MEDICAID |