Provider Demographics
NPI:1821705849
Name:FLEB PLLC
Entity Type:Organization
Organization Name:FLEB PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROADAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:870-926-5168
Mailing Address - Street 1:3103 FLEMON RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8920
Mailing Address - Country:US
Mailing Address - Phone:870-926-5168
Mailing Address - Fax:
Practice Address - Street 1:2000 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4348
Practice Address - Country:US
Practice Address - Phone:870-203-6177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty