Healthcare Provider Details

I. General information

NPI: 1760115901
Provider Name (Legal Business Name): WINTRESS BLYTH MCCORMICK LPN, CBC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7020 HIGHWAY 190 STE C
COVINGTON LA
70433-4962
US

IV. Provider business mailing address

7020 HIGHWAY 190 STE C
COVINGTON LA
70433-4962
US

V. Phone/Fax

Practice location:
  • Phone: 985-871-7337
  • Fax: 985-871-7600
Mailing address:
  • Phone: 985-871-7337
  • Fax: 985-871-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number20180342
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number22098
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: