Provider Demographics
NPI:1689158909
Name:PHILLIPS, LEAH DENISE (FNP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:DENISE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 LINE ST S
Mailing Address - Street 2:STE 1
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-2144
Mailing Address - Country:US
Mailing Address - Phone:601-504-6430
Mailing Address - Fax:
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:601-483-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902939363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner