Healthcare Provider Details

I. General information

NPI: 1669165239
Provider Name (Legal Business Name): EBONY EAGLIN MSN, APRN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALTERS ST
LAKE CHARLES LA
70607-4647
US

IV. Provider business mailing address

PO BOX 122108 DEPT 2108
DALLAS TX
75312-0001
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-8100
  • Fax:
Mailing address:
  • Phone: 337-494-2921
  • Fax: 337-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number229790
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number229790
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: