Healthcare Provider Details

I. General information

NPI: 1619708948
Provider Name (Legal Business Name): MGPMHNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 EVERGREEN ST
BUNKIE LA
71322-1307
US

IV. Provider business mailing address

PO BOX 142
PITKIN LA
70656-0142
US

V. Phone/Fax

Practice location:
  • Phone: 318-346-3143
  • Fax:
Mailing address:
  • Phone: 337-226-8938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MEGAN LEE ANN TRASK
Title or Position: SOLE OWNER
Credential: PMHNP-BC
Phone: 337-226-8938