Healthcare Provider Details

I. General information

NPI: 1891076865
Provider Name (Legal Business Name): GWENDOLYN LEGER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 S BROADWAY ST
CHURCH POINT LA
70525-4402
US

IV. Provider business mailing address

9155 CRESTWYN HILLS DR
MEMPHIS TN
38125-8501
US

V. Phone/Fax

Practice location:
  • Phone: 337-684-3178
  • Fax:
Mailing address:
  • Phone: 901-261-4858
  • Fax: 901-261-4867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP06544
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN071795
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: