Healthcare Provider Details

I. General information

NPI: 1235376096
Provider Name (Legal Business Name): LEIGH ANN BONVILLAIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2009
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

4501 HWY 39 N APT 13F
MERIDIAN MS
39301-1076
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-4124
  • Fax:
Mailing address:
  • Phone: 601-479-2924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR869889
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: