Healthcare Provider Details

I. General information

NPI: 1013548296
Provider Name (Legal Business Name): COLLEEN LEO FRADY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: COLLEEN TEEL FNP

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 JUDGE TANNER BLVD
COVINGTON LA
70433-7500
US

IV. Provider business mailing address

902 MAINE AVE
SLIDELL LA
70458-3546
US

V. Phone/Fax

Practice location:
  • Phone: 985-867-8585
  • Fax:
Mailing address:
  • Phone: 985-774-9642
  • Fax: 985-256-5687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number211473
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: