Provider Demographics
NPI:1760615595
Name:LEACH, SHELLEY S (FNP)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:S
Last Name:LEACH
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 1:1842 SIMPSON HIGHWAY 149
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114-3438
Mailing Address - Country:US
Mailing Address - Phone:601-847-7130
Mailing Address - Fax:601-847-7130
Practice Address - Street 1:202 JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:NEW HEBRON
Practice Address - State:MS
Practice Address - Zip Code:39140
Practice Address - Country:US
Practice Address - Phone:601-694-2116
Practice Address - Fax:601-694-2119
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00476391Medicaid