MEDICARE: LESLIE TABB NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R855837	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	500011524	OTHER	MS	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316916844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE TABB NP

Provider Business Mailing Address
First Line	:	803 1ST ST
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2309
Country	:	US
Telephone Number	:	662-843-2721
Fax Number	:

Provider Business Practice Location Address
First Line	:	803 1ST ST
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2309
Country	:	US
Telephone Number	:	662-843-2721
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	11/21/2016

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