Healthcare Provider Details

I. General information

NPI: 1992491807
Provider Name (Legal Business Name): LETICIA HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 STONE BROOK CV
RIPLEY TN
38063-8071
US

IV. Provider business mailing address

423 N FOWLKES AVE
DYERSBURG TN
38024-3817
US

V. Phone/Fax

Practice location:
  • Phone: 731-612-8129
  • Fax: 731-260-2693
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number40003
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number1791408
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: