Provider Demographics
NPI:1851399554
Name:SMITH-LEACH, NANCY E (NP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:E
Last Name:SMITH-LEACH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1011 S EAST ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1331
Mailing Address - Country:US
Mailing Address - Phone:417-466-7191
Mailing Address - Fax:417-466-3876
Practice Address - Street 1:1011 S EAST ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1331
Practice Address - Country:US
Practice Address - Phone:417-466-7191
Practice Address - Fax:417-466-3876
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113916363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506125400Medicaid
MO506125400Medicaid
MOS39934Medicare UPIN