Provider Demographics
NPI:1538285267
Name:CARR, LEISA GAYLE
Entity type:Individual
Prefix:MRS
First Name:LEISA
Middle Name:GAYLE
Last Name:CARR
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 1:707 E OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:SULPHUR
Mailing Address - State:OK
Mailing Address - Zip Code:73086-3038
Mailing Address - Country:US
Mailing Address - Phone:580-622-6788
Mailing Address - Fax:
Practice Address - Street 1:707 E OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-3038
Practice Address - Country:US
Practice Address - Phone:580-622-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK172A00000X172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20091200AMedicaid