Provider Demographics
NPI:1477104271
Name:GAULT, LEIGH ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ELLEN
Last Name:GAULT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 ROSALIE CT
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6053
Mailing Address - Country:US
Mailing Address - Phone:601-946-8888
Mailing Address - Fax:
Practice Address - Street 1:4500 I 55 N STE 128
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5960
Practice Address - Country:US
Practice Address - Phone:601-374-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily