1174811517 NPI number — MS. HEATHER BOZEMAN LENSING NP-C

Table of content: MS. HEATHER BOZEMAN LENSING NP-C (NPI 1174811517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174811517 NPI number — MS. HEATHER BOZEMAN LENSING NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LENSING
Provider First Name:
HEATHER
Provider Middle Name:
BOZEMAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1174811517
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 DESIARD ST
Provider Second Line Business Mailing Address:
SUITE 355
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71201-7319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-807-7875
Provider Business Mailing Address Fax Number:
318-812-6603

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
920 OLIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71201-5702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-807-6267
Provider Business Practice Location Address Fax Number:
318-812-6458
Provider Enumeration Date:
07/19/2011

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:  728472 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP07798 , 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: 2377507 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 852N78 . This is a "BLUE CROSS AND BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 284172801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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