Provider Demographics
NPI:1063021087
Name:TRIVETT, LESLIE RENEE (APRN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:RENEE
Last Name:TRIVETT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JONESBOROUGH
Mailing Address - State:TN
Mailing Address - Zip Code:37659-1425
Mailing Address - Country:US
Mailing Address - Phone:770-337-1418
Mailing Address - Fax:
Practice Address - Street 1:1025 EXECUTIVE PARK BLVD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4620
Practice Address - Country:US
Practice Address - Phone:423-830-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28014363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty