Healthcare Provider Details

I. General information

NPI: 1841029865
Provider Name (Legal Business Name): LEAH JORDAN GUNDERMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S GLOSTER ST
TUPELO MS
38801-4996
US

IV. Provider business mailing address

207 WOODMONT DR
RUSSELLVILLE AL
35653-5873
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-3000
  • Fax:
Mailing address:
  • Phone: 256-665-2225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-181400
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: