Healthcare Provider Details

I. General information

NPI: 1942977301
Provider Name (Legal Business Name): LEAH CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 01/09/2022
Certification Date: 01/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 HORIZAN RD STE 4
WEST MEMPHIS AR
72301-2926
US

IV. Provider business mailing address

401 COUNTRY CLUB RD
WEST MEMPHIS AR
72301-3883
US

V. Phone/Fax

Practice location:
  • Phone: 870-732-0332
  • Fax:
Mailing address:
  • Phone: 501-766-6774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number217600
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number30222
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number217600
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR093788
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: