Healthcare Provider Details

I. General information

NPI: 1528514346
Provider Name (Legal Business Name): LEEANN DEPRIEST NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 PARR AVE SUITE D
DYERSBURG TN
38024-2074
US

IV. Provider business mailing address

PO BOX 688
DYERSBURG TN
38025-0688
US

V. Phone/Fax

Practice location:
  • Phone: 731-288-0911
  • Fax: 731-288-0065
Mailing address:
  • Phone: 731-288-0911
  • Fax: 731-288-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21355
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: