Healthcare Provider Details

I. General information

NPI: 1013426329
Provider Name (Legal Business Name): FIG LEAF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 SOUTH ST
CALEDONIA MS
39740
US

IV. Provider business mailing address

171 SOUTH ST
CALEDONIA MS
39740-8587
US

V. Phone/Fax

Practice location:
  • Phone: 662-251-7389
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR858548
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMANDA FONDREN
Title or Position: NURSE PRACTITIONER/OWNER
Credential: FNP-C
Phone: 662-855-0080