Healthcare Provider Details

I. General information

NPI: 1386536407
Provider Name (Legal Business Name): LESLIE MICHELLE RAGGETT DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE MICHELLE WILSON FNP-C

II. Dates (important events)

Enumeration Date: 07/15/2025
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 SOUTHCREST PKWY STE 109
SOUTHAVEN MS
38671-4852
US

IV. Provider business mailing address

5947 BRICE CV N
OLIVE BRANCH MS
38654-3529
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-9116
  • Fax:
Mailing address:
  • Phone: 901-288-3282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907603
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: