Provider Demographics
NPI:1629302823
Name:LEISTER, TIFFANY (NP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LEISTER
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 1:1300 ACCESS RD STE 400
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5211
Mailing Address - Country:US
Mailing Address - Phone:662-281-1115
Mailing Address - Fax:662-281-1113
Practice Address - Street 1:2209 JEFFERSON DAVIS DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5221
Practice Address - Country:US
Practice Address - Phone:662-281-1115
Practice Address - Fax:662-281-1113
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS871899363LF0000X
MSR871899363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02876000Medicaid