Basic Information
| Provider Information | |||||||||
| NPI: | 1760615595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEACH | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1842 SIMPSON HIGHWAY 149 | ||||||||
| Address2: | |||||||||
| City: | MENDENHALL | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391143438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018477130 | ||||||||
| FaxNumber: | 6018477130 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 JEFFERSON STREET | ||||||||
| Address2: | |||||||||
| City: | NEW HEBRON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016942116 | ||||||||
| FaxNumber: | 6016942119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2009 | ||||||||
| LastUpdateDate: | 09/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R863242 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 00476391 | 05 | MS | MEDICAID |