Healthcare Provider Details

I. General information

NPI: 1306655311
Provider Name (Legal Business Name): ISLAND SIDE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2025
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 WOODVALE AVE
LAFAYETTE LA
70503-3434
US

IV. Provider business mailing address

414 WOODVALE AVE
LAFAYETTE LA
70503-3434
US

V. Phone/Fax

Practice location:
  • Phone: 337-326-0202
  • Fax:
Mailing address:
  • Phone: 337-326-0202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA PENA MILLER
Title or Position: NURSE PRACTITIONER
Credential: APRN
Phone: 337-326-0202