Healthcare Provider Details

I. General information

NPI: 1144673344
Provider Name (Legal Business Name): JANCI BIENVENU DETWILER CPNP-PC/AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6917
US

IV. Provider business mailing address

612 BURLINGTON CIR
BROUSSARD LA
70518-7414
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-2017
  • Fax: 337-470-2809
Mailing address:
  • Phone: 337-224-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberAP08962
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP08962
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: