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General NPI Number Information
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NPI Number | 1326816661
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Entity Type | Organization
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Legal Business Name | CANNARELEAF
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Dates
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Enumeration Date | 12/15/2023
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Last Update Date | 02/10/2024
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Provider Practice Location Address
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Address Line | 230 GOODMAN RD E STE 201
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City | SOUTHAVEN
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State | MS
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Zip | 38671-5151
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Country | US
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Telephone | 662-384-6949
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Fax |
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Provider Business Mailing Address
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Address Line | 6822 SAINT MICHEALS
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-9604
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. HEATHER LUCAS
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Credential | NURSE PRACTITIONER
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Telephone | 870-394-6591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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