Provider Demographics
NPI:1336586171
Name:LEEKS, PHAGEN
Entity type:Individual
Prefix:
First Name:PHAGEN
Middle Name:
Last Name:LEEKS
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 1:2792 S 2ND ST STE B
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7064
Mailing Address - Country:US
Mailing Address - Phone:870-932-3600
Mailing Address - Fax:
Practice Address - Street 1:2792 S 2ND ST STE B
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7064
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
AR120253164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No174400000XOther Service ProvidersSpecialist