Healthcare Provider Details

I. General information

NPI: 1710961677
Provider Name (Legal Business Name): STACEY SMITH PERRAULT N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY LEIGH SMITH

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5339 DIDESSE DR
BATON ROUGE LA
70808-4306
US

IV. Provider business mailing address

5339 DIDESSE DR
BATON ROUGE LA
70808-4306
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-3076
  • Fax: 225-765-3090
Mailing address:
  • Phone: 225-765-3076
  • Fax: 225-765-3090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04588
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: