Provider Demographics
NPI:1316916844
Name:TABB, LESLIE (NP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:TABB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2309
Mailing Address - Country:US
Mailing Address - Phone:662-843-2721
Mailing Address - Fax:
Practice Address - Street 1:803 1ST ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2309
Practice Address - Country:US
Practice Address - Phone:662-843-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855837363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS500011524OtherMEDICARE RAILROAD
MS00121836Medicaid
MS$$$$$$$$$OtherFEDERAL TAX IDENTIFICATION NUMBER
MS302I502462Medicare PIN