Provider Demographics
NPI:1407109945
Name:BYRD, LEA ANN (APRN)
Entity Type:Individual
Prefix:MS
First Name:LEA
Middle Name:ANN
Last Name:BYRD
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:PO BOX 289
Mailing Address - Street 2:
Mailing Address - City:MARKS
Mailing Address - State:MS
Mailing Address - Zip Code:38646-0289
Mailing Address - Country:US
Mailing Address - Phone:662-326-3500
Mailing Address - Fax:
Practice Address - Street 1:1024 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1832
Practice Address - Country:US
Practice Address - Phone:662-326-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR823849363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06678813Medicaid