1588040703 NPI number — EMILY WILLARD NP

Table of content: EMILY WILLARD NP (NPI 1588040703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588040703 NPI number — EMILY WILLARD NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLARD
Provider First Name:
EMILY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1588040703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
604 N ACADIA RD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THIBODAUX
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70301-4897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
985-446-5079
Provider Business Mailing Address Fax Number:
985-447-2497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 FRONT ST STE 2126
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71373-2835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-414-9336
Provider Business Practice Location Address Fax Number:
318-599-1178
Provider Enumeration Date:
08/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP08458 , 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: 2400959 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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