Provider Demographics
NPI:1033514591
Name:EVANS, LEANN NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:LEANN
Middle Name:NICOLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-8700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:404 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW AUGUSTA
Practice Address - State:MS
Practice Address - Zip Code:39462-0000
Practice Address - Country:US
Practice Address - Phone:601-964-8391
Practice Address - Fax:601-964-8393
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR880882363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07759844Medicaid
MS12771131OtherCAQH NUMBER
MS379954YJ9FMedicare PIN