Provider Demographics
NPI:1720377641
Name:WOMBLE, LEIGH BOSTICK (FNP)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:BOSTICK
Last Name:WOMBLE
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 1:512 LEVEE STREET, BOX 310
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38769-0310
Mailing Address - Country:US
Mailing Address - Phone:662-759-6806
Mailing Address - Fax:662-759-6771
Practice Address - Street 1:512 LEVEE STREET, BOX 310
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MS
Practice Address - Zip Code:38769-0310
Practice Address - Country:US
Practice Address - Phone:662-759-6806
Practice Address - Fax:662-759-6771
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR544779364SF0001X
GARN210599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health