1760720353 NPI number — DEAVON ALISHA PETERSON FNP-C

Table of content: DEAVON ALISHA PETERSON FNP-C (NPI 1760720353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760720353 NPI number — DEAVON ALISHA PETERSON FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
DEAVON
Provider Middle Name:
ALISHA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
DEAVON
Provider Other Middle Name:
CORMIER
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760720353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1103 KALISTE SALOOM RD STE 208
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70508-5784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-234-3757
Provider Business Mailing Address Fax Number:
337-234-3733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1103 KALISTE SALOOM RD STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-234-3757
Provider Business Practice Location Address Fax Number:
337-234-3733
Provider Enumeration Date:
01/17/2013

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:  AP07245 , 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: 2324217 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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