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General NPI Number Information
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NPI Number | 1164759965
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Entity Type | Individual
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Provider Name | TYRONE LEAVETTE RUPERT N.P.
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Gender | Male
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Dates
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Enumeration Date | 11/16/2009
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Last Update Date | 11/16/2009
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Provider Practice Location Address
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Address Line | 824 ALABAMA ST
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City | COLUMBUS
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State | MS
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Zip | 39702-5436
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Country | US
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Telephone | 662-244-0391
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Fax |
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Provider Business Mailing Address
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Address Line | 3119 SIERRA CT
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City | COLUMBUS
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State | MS
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Zip | 39705-1807
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Country | US
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Telephone | 662-889-3246
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R867788
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License Number State | MS
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