Basic Information
| Provider Information | |||||||||
| NPI: | 1104159904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | LEILA | ||||||||
| MiddleName: | KEEL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 400 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383020400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314220213 | ||||||||
| FaxNumber: | 7314255743 | ||||||||
| Practice Location | |||||||||
| Address1: | 2863 HIGHWAY 45 BYP | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383053618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608300 | ||||||||
| FaxNumber: | 7316608301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 13090 | TN | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 367A00000X | APN14288 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | APRN90339MIDWIFE | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 14288 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 3380640 | 01 | TN | MEDICARE GROUP | OTHER | 3380640 | 01 | TN | MEDICAID GROUP | OTHER | 1525515 | 05 | TN | MEDICAID |