Provider Demographics
NPI:1013426329
Name:FIG LEAF, LLC
Entity type:Organization
Organization Name:FIG LEAF, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONDREN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:662-855-0080
Mailing Address - Street 1:171 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MS
Mailing Address - Zip Code:39740-8587
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:171 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MS
Practice Address - Zip Code:39740
Practice Address - Country:US
Practice Address - Phone:662-251-7389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LC1500X, 363LF0000X, 363LP2300X
MSR858548363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851792626OtherNPI