Healthcare Provider Details

I. General information

NPI: 1780932939
Provider Name (Legal Business Name): LEAH T ELROD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 WESTLAND DR SW
CLEVELAND TN
37311-8163
US

IV. Provider business mailing address

PO BOX 308
BENTON TN
37307-0308
US

V. Phone/Fax

Practice location:
  • Phone: 423-478-1970
  • Fax:
Mailing address:
  • Phone: 423-338-8995
  • Fax: 423-338-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26635
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number164926
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: