Basic Information
| Provider Information | |||||||||
| NPI: | 1659316248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRISTER | ||||||||
| FirstName: | LEIGH | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERRINGTON | ||||||||
| OtherFirstName: | LEIGH | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 147 CARMICHAEL BLVD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391106368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012098272 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 N. STATE ST. | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R869571 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 00975577 | 05 | MS | MEDICAID |