Provider Demographics
NPI:1578923454
Name:WORDLAW, LEASE (NURSE PRACTITONER)
Entity Type:Individual
Prefix:
First Name:LEASE
Middle Name:
Last Name:WORDLAW
Suffix:
Gender:F
Credentials:NURSE PRACTITONER
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 373
Mailing Address - Street 2:
Mailing Address - City:MABEN
Mailing Address - State:MS
Mailing Address - Zip Code:39750-0373
Mailing Address - Country:US
Mailing Address - Phone:662-312-2737
Mailing Address - Fax:
Practice Address - Street 1:1815 WATERSHED DR
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-8471
Practice Address - Country:US
Practice Address - Phone:662-312-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901466364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health