Healthcare Provider Details

I. General information

NPI: 1659598795
Provider Name (Legal Business Name): MARY TRICHE MORON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 12TH ST
LAFAYETTE LA
70501-6224
US

IV. Provider business mailing address

806 JEFFERSON TER
NEW IBERIA LA
70560-5727
US

V. Phone/Fax

Practice location:
  • Phone: 337-534-0107
  • Fax: 337-534-0184
Mailing address:
  • Phone: 337-367-3992
  • Fax: 337-367-3994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP03778
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: