Provider Demographics
NPI:1447786801
Name:TYNES, LESLIE (AGACNP, RNFA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TYNES
Suffix:
Gender:F
Credentials:AGACNP, RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5500
Mailing Address - Fax:601-984-5503
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5500
Practice Address - Fax:601-984-5503
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903191163WR0006X, 363L00000X, 363LA2100X
AL1-111893363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01574210Medicaid