Healthcare Provider Details

I. General information

NPI: 1548448186
Provider Name (Legal Business Name): TENNILLE L LEFTWICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 W 15TH ST
PLANO TX
75075-7738
US

IV. Provider business mailing address

3901 W 15TH ST
PLANO TX
75075-7738
US

V. Phone/Fax

Practice location:
  • Phone: 469-562-1265
  • Fax: 469-484-0648
Mailing address:
  • Phone: 469-562-1265
  • Fax: 469-484-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberPA05559
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA05559
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: