Healthcare Provider Details

I. General information

NPI: 1114078839
Provider Name (Legal Business Name): LISA PENTON MEJIA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA PENTON HERRING APRN

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 PLAZA ST STE 38
BOGALUSA LA
70427-3729
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 987-730-2284
  • Fax: 985-730-2305
Mailing address:
  • Phone: 225-526-0018
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP04640
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP04640
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: