Healthcare Provider Details

I. General information

NPI: 1225565807
Provider Name (Legal Business Name): LATRICE SHONTA MALLARD MAM, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2017
Last Update Date: 09/29/2026
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 AVENUE G
KENTWOOD LA
70444-2601
US

IV. Provider business mailing address

PO BOX 40984
BATON ROUGE LA
70835-0984
US

V. Phone/Fax

Practice location:
  • Phone: 225-315-1357
  • Fax:
Mailing address:
  • Phone: 225-315-1357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number229471
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number117290
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: