Healthcare Provider Details

I. General information

NPI: 1750653382
Provider Name (Legal Business Name): LESA COLLEEN WHITEHEAD NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

434 N CAPTAIN GLOSTER DR
GLOSTER MS
39638-3401
US

IV. Provider business mailing address

PO BOX 639
CENTREVILLE MS
39631-0639
US

V. Phone/Fax

Practice location:
  • Phone: 601-225-4711
  • Fax: 601-225-7861
Mailing address:
  • Phone: 601-645-5221
  • Fax: 601-645-5842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR853722
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: