Provider Demographics
NPI:1477269306
Name:O'FALLON, LEIA DAWN (ANP)
Entity Type:Individual
Prefix:MRS
First Name:LEIA
Middle Name:DAWN
Last Name:O'FALLON
Suffix:
Gender:F
Credentials:ANP
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 509
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-0509
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:535 JORDAN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5714
Practice Address - Country:US
Practice Address - Phone:870-367-6246
Practice Address - Fax:855-926-7383
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01586363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology