Provider Demographics
NPI:1780141044
Name:KETCHUM, LEAH (NP)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:317 HIGHWAY 13 S
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:MS
Practice Address - Zip Code:39117-3353
Practice Address - Country:US
Practice Address - Phone:601-732-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903189363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner