Healthcare Provider Details

I. General information

NPI: 1144556622
Provider Name (Legal Business Name): NIKKI CLARY LEGLUE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

IV. Provider business mailing address

4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

V. Phone/Fax

Practice location:
  • Phone: 337-521-9100
  • Fax:
Mailing address:
  • Phone: 337-521-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200293
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: