Provider Demographics
NPI:1104592955
Name:ROSS, LEAH OLIVIA
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:OLIVIA
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SOUTH MAY DRIVE, DUMAS, AR, USA
Mailing Address - Street 2:
Mailing Address - City:DUMAS
Mailing Address - State:AR
Mailing Address - Zip Code:71639
Mailing Address - Country:US
Mailing Address - Phone:870-377-3050
Mailing Address - Fax:
Practice Address - Street 1:940 OLD WARREN ROAD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655
Practice Address - Country:US
Practice Address - Phone:870-377-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216451363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily