Provider Demographics
NPI:1750653382
Name:WHITEHEAD, LESA COLLEEN (NP-C)
Entity Type:Individual
Prefix:
First Name:LESA
Middle Name:COLLEEN
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:NP-C
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 639
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39631-0639
Mailing Address - Country:US
Mailing Address - Phone:601-645-5221
Mailing Address - Fax:601-645-5842
Practice Address - Street 1:434 N CAPTAIN GLOSTER DR
Practice Address - Street 2:
Practice Address - City:GLOSTER
Practice Address - State:MS
Practice Address - Zip Code:39638-3401
Practice Address - Country:US
Practice Address - Phone:601-225-4711
Practice Address - Fax:601-225-7861
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily