MEDICARE: MS. PAULA SUE LEATHERS NNP-BC

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	363LN0005X	Critical Care Neonatal Nurse Practitioner	508314	TX

General Provider Information

NPI Number	:	1477710218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAULA SUE LEATHERS NNP-BC

Provider Business Mailing Address
First Line	:	401 JIM SHARP BLVD
Second Line	:
City	:	KERMIT
State	:	TX
Zip	:	79745-5229
Country	:	US
Telephone Number	:	432-586-2483
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 W 4TH ST
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79763-4368
Country	:	US
Telephone Number	:	432-335-5270
Fax Number	:

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

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	05/20/2008

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