=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982312476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY ANN LEIGH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2022
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27950 S 620 RD
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74344-7984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-396-4967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27950 S 620 RD
-----------------------------------------------------
City | GROVE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74344-7984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-396-4967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZA2600X
-----------------------------------------------------
Taxonomy Name | Medical Art Specialist/Technologist
-----------------------------------------------------
License Number | P081370054
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------