Healthcare Provider Details

I. General information

NPI: 1568824019
Provider Name (Legal Business Name): ELIJAH BOOTHE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 OLD COLUMBIA RD
HARRISONBURG LA
71340-3001
US

IV. Provider business mailing address

192 BASTILLE LN SUITE 200
RUSTON LA
71270-7149
US

V. Phone/Fax

Practice location:
  • Phone: 318-744-2121
  • Fax:
Mailing address:
  • Phone: 318-475-0779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07815
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN132128
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: