Provider Demographics
NPI:1003392416
Name:LEAVY, MONTOYAE C (NP)
Entity Type:Individual
Prefix:MISS
First Name:MONTOYAE
Middle Name:C
Last Name:LEAVY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122A RICHMOND TRL NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-4077
Mailing Address - Country:US
Mailing Address - Phone:601-400-1375
Mailing Address - Fax:
Practice Address - Street 1:747 INDUSTRIAL PARK RD NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2065
Practice Address - Country:US
Practice Address - Phone:601-833-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902224363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner