Healthcare Provider Details

I. General information

NPI: 1619548872
Provider Name (Legal Business Name): JNICHOLAS FNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 LATIOLAIS DR
BREAUX BRIDGE LA
70517-4231
US

IV. Provider business mailing address

400 HIGHWAY 1252
CARENCRO LA
70520-5360
US

V. Phone/Fax

Practice location:
  • Phone: 337-274-2783
  • Fax:
Mailing address:
  • Phone: 337-274-2783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JULIE O NICHOLAS
Title or Position: SOLE MEMBER/OWNER
Credential: FNP
Phone: 337-274-2783