Provider Demographics
NPI:1083272892
Name:LESURE, TAMARA ALICIA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ALICIA
Last Name:LESURE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6355 NESTING DOVE
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-4700
Mailing Address - Country:US
Mailing Address - Phone:662-812-7685
Mailing Address - Fax:
Practice Address - Street 1:6355 NESTING DOVE
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-4700
Practice Address - Country:US
Practice Address - Phone:662-812-7685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN89655376K00000X
TN374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide