Healthcare Provider Details

I. General information

NPI: 1306767702
Provider Name (Legal Business Name): DEMETRICA LEAVY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 PECAN PARK DR
RIDGELAND MS
39157-2817
US

IV. Provider business mailing address

203 PECAN PARK DR
RIDGELAND MS
39157-2817
US

V. Phone/Fax

Practice location:
  • Phone: 662-809-3755
  • Fax:
Mailing address:
  • Phone: 662-809-3755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberF5W7L9G6
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: