Healthcare Provider Details

I. General information

NPI: 1255994166
Provider Name (Legal Business Name): LESLIE CARROLL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W FOREST AVE STE 200
JACKSON TN
38301-3940
US

IV. Provider business mailing address

183 UNION AVE
JACKSON TN
38301-6036
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-9490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number25734
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: