Healthcare Provider Details

I. General information

NPI: 1578552188
Provider Name (Legal Business Name): LEO ROURKE ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9075 SANDIDGE CENTER CV
OLIVE BRANCH MS
38654-3514
US

IV. Provider business mailing address

9075 SANDIDGE CENTER CV
OLIVE BRANCH MS
38654-3514
US

V. Phone/Fax

Practice location:
  • Phone: 662-893-8484
  • Fax: 662-893-1103
Mailing address:
  • Phone: 662-893-8484
  • Fax: 662-893-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000006732
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901896
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: