Provider Demographics
NPI:1780775619
Name:LEATHERS, BREANNE NUNNALLY (DNP, FNP)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:NUNNALLY
Last Name:LEATHERS
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:ELIZABETH
Other - Last Name:NUNNALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 U S HIGHWAY 98
Practice Address - Street 2:SUITE 101
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8577
Practice Address - Country:US
Practice Address - Phone:601-261-1500
Practice Address - Fax:601-296-7549
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN211057363LF0000X
MSR870133363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09701839Medicaid
MS2270698OtherCIGNA
MS3514174OtherUNITED HEALTHCARE
MS9634922OtherAETNA
MS2270698OtherCIGNA