Healthcare Provider Details

I. General information

NPI: 1760719447
Provider Name (Legal Business Name): LEITA N STARK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 11/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 HIGHWAY 363
MANTACHIE MS
38855-7197
US

IV. Provider business mailing address

95 IVIE LN
MANTACHIE MS
38855-8383
US

V. Phone/Fax

Practice location:
  • Phone: 662-282-4226
  • Fax:
Mailing address:
  • Phone: 662-322-3278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR862379
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: