Healthcare Provider Details

I. General information

NPI: 1659300143
Provider Name (Legal Business Name): MARY BETH GAUDIN CANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42388 PELICAN PROFESSIONAL PARK
HAMMOND LA
70403
US

IV. Provider business mailing address

167 SOUTH GATE
PONCHATOULA LA
70454
US

V. Phone/Fax

Practice location:
  • Phone: 985-542-6251
  • Fax:
Mailing address:
  • Phone: 985-542-6251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP03655
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: