Healthcare Provider Details

I. General information

NPI: 1619432705
Provider Name (Legal Business Name): ELAINE MARIE WAGUESPACK APRN - FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELAINE MARIE WAGUESPACK APRN - FNP

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 ALBERTSON PKWY
BROUSSARD LA
70518-4349
US

IV. Provider business mailing address

803 ALBERTSON PKWY
BROUSSARD LA
70518-4349
US

V. Phone/Fax

Practice location:
  • Phone: 337-889-5364
  • Fax: 337-232-0477
Mailing address:
  • Phone: 337-889-5364
  • Fax: 337-232-0477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP10134
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10134
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: