Healthcare Provider Details

I. General information

NPI: 1477203073
Provider Name (Legal Business Name): LEIGHTON SERIO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 GOODLOE RD
CANTON MS
39046-8732
US

IV. Provider business mailing address

285 GOODLOE RD
CANTON MS
39046-8732
US

V. Phone/Fax

Practice location:
  • Phone: 601-862-9115
  • Fax:
Mailing address:
  • Phone: 601-862-9115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR901413
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: