Provider Demographics
NPI:1760615595
Name:LEACH, SHELLEY S (FNP)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:S
Last Name:LEACH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 MANGUM AVE
Mailing Address - Street 2:
Mailing Address - City:MENDENHALL
Mailing Address - State:MS
Mailing Address - Zip Code:39114
Mailing Address - Country:US
Mailing Address - Phone:601-847-5111
Mailing Address - Fax:601-847-3060
Practice Address - Street 1:820 MANGUM AVE
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114
Practice Address - Country:US
Practice Address - Phone:601-847-5111
Practice Address - Fax:601-847-3060
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00476391Medicaid