1043601685 NPI number — PSYCHIATRIC NURSE PRACTITIONERS

Table of content: (NPI 1043601685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043601685 NPI number — PSYCHIATRIC NURSE PRACTITIONERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHIATRIC NURSE PRACTITIONERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043601685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2208 KIBER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHREVEPORT
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71104-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-560-5883
Provider Business Mailing Address Fax Number:
318-617-1590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1651 E 70TH ST # 382
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHREVEPORT
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71105-5115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-560-5883
Provider Business Practice Location Address Fax Number:
318-216-3940
Provider Enumeration Date:
02/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
KNIGHT
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING ADMIN
Authorized Official Telephone Number:
845-551-9673

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  RN79944 AP3962 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3962 . This is a "ADVANCE PRACTICE (AP) LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 35169 . This is a "CDS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 79944 . This is a "RN LICENSE NO." identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 30188717 . This is a "ANCC CREDENTIALING" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1032026 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 210016 . This is a "PRESCRIPTIVE AUTHORITY (PA)" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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