Healthcare Provider Details

I. General information

NPI: 1063259620
Provider Name (Legal Business Name): STEPHANIE SIMON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 W GAUTHIER RD STE 150
LAKE CHARLES LA
70605-7119
US

IV. Provider business mailing address

604 N ACADIA RD STE 101
THIBODAUX LA
70301-4897
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-5559
  • Fax:
Mailing address:
  • Phone: 985-446-5079
  • Fax: 985-447-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number237223
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN147315
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: