=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730546276
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEIGH ANNE SHOCKLEY MSN-APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2016
-----------------------------------------------------
Last Update Date | 10/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 E WALNUT ST
-----------------------------------------------------
City | GURDON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71743-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-353-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 CYPRESS CT
-----------------------------------------------------
City | ARKADELPHIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71923-9388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-203-8440
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A004623
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------