Healthcare Provider Details

I. General information

NPI: 1124793658
Provider Name (Legal Business Name): KATELYN WREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6485 GROOM RD
BAKER LA
70714-4335
US

IV. Provider business mailing address

505 BERNARD ST
NEW ROADS LA
70760-3221
US

V. Phone/Fax

Practice location:
  • Phone: 225-614-9471
  • Fax:
Mailing address:
  • Phone: 225-240-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPST0246
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: