Healthcare Provider Details

I. General information

NPI: 1831196096
Provider Name (Legal Business Name): JONI FERGUSON NICKENS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2005
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 NORTH BLVD STE 101
BATON ROUGE LA
70806-4043
US

IV. Provider business mailing address

42076 HIGHWAY 933
PRAIRIEVILLE LA
70769-6106
US

V. Phone/Fax

Practice location:
  • Phone: 225-341-5901
  • Fax: 225-341-5903
Mailing address:
  • Phone: 225-622-2048
  • Fax: 225-319-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN062230AP03515
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: