Provider Demographics
NPI:1114059961
Name:HARRELL, LEATHA EVELYN (MSN, RN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LEATHA
Middle Name:EVELYN
Last Name:HARRELL
Suffix:
Gender:F
Credentials:MSN, RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:6905 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-5857
Mailing Address - Country:US
Mailing Address - Phone:817-430-3903
Mailing Address - Fax:
Practice Address - Street 1:375 MUNICIPAL DR
Practice Address - Street 2:SUITE 242
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3559
Practice Address - Country:US
Practice Address - Phone:972-952-0290
Practice Address - Fax:972-952-0293
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX437929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A9034Medicare ID - Type Unspecified
TXR59753Medicare UPIN