Provider Demographics
NPI:1174160618
Name:DEJESUS, ERIN LEIGH (NP)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:LEIGH
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 W RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382
Mailing Address - Country:US
Mailing Address - Phone:276-288-8686
Mailing Address - Fax:
Practice Address - Street 1:375 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382
Practice Address - Country:US
Practice Address - Phone:276-228-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty