Healthcare Provider Details

I. General information

NPI: 1588719215
Provider Name (Legal Business Name): CHAQUETTA THOMAS JOHNSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5604A COLISEUM BLVD
ALEXANDRIA LA
71303-3709
US

IV. Provider business mailing address

139 GEORGETOWN DR
ALEXANDRIA LA
71303-3604
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-5282
  • Fax: 318-487-5338
Mailing address:
  • Phone: 318-448-2447
  • Fax: 318-487-5338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP03956
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: