Provider Demographics
NPI:1154747889
Name:PACK, LEABETH MACON (NP-C)
Entity type:Individual
Prefix:MRS
First Name:LEABETH
Middle Name:MACON
Last Name:PACK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 W MAIN ST
Mailing Address - Street 2:STE 201
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3100
Mailing Address - Country:US
Mailing Address - Phone:615-444-1180
Mailing Address - Fax:615-449-6148
Practice Address - Street 1:1430 W BADDOUR PKWY STE A
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2656
Practice Address - Country:US
Practice Address - Phone:615-453-6144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-05
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18455363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily