Provider Demographics
NPI:1003111543
Name:SHAVERS, LESLIE ESTES (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ESTES
Last Name:SHAVERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:RENEE
Other - Last Name:ESTES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:12508 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-7621
Mailing Address - Country:US
Mailing Address - Phone:228-861-7744
Mailing Address - Fax:
Practice Address - Street 1:2210 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-3416
Practice Address - Country:US
Practice Address - Phone:228-372-6043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily