Healthcare Provider Details

I. General information

NPI: 1336506922
Provider Name (Legal Business Name): CODIE JESSICA LEE GUIDRY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 N HIGHWAY 171 STE 10
LAKE CHARLES LA
70611-5374
US

IV. Provider business mailing address

277 N HIGHWAY 171 STE 10
LAKE CHARLES LA
70611-5374
US

V. Phone/Fax

Practice location:
  • Phone: 337-217-7762
  • Fax:
Mailing address:
  • Phone: 337-217-7762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP08635
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN128288
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: