Healthcare Provider Details

I. General information

NPI: 1215065073
Provider Name (Legal Business Name): ANDRE GERVAIS GROS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 BELANGER ST SUITE 102
HOUMA LA
70360-4463
US

IV. Provider business mailing address

855 BELANGER STREET STE 102
HOUMA LA
70360
US

V. Phone/Fax

Practice location:
  • Phone: 985-873-0112
  • Fax: 985-857-8624
Mailing address:
  • Phone: 985-873-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPO3855
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: