Healthcare Provider Details

I. General information

NPI: 1528986155
Provider Name (Legal Business Name): PEYTIN DELISSE TARVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIKEY DELISSE TARVER

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14635 S HARRELLS FERRY RD STE 3A
BATON ROUGE LA
70816-2960
US

IV. Provider business mailing address

1483 LILA ST
BATON ROUGE LA
70820-6417
US

V. Phone/Fax

Practice location:
  • Phone: 225-349-8984
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: