Healthcare Provider Details

I. General information

NPI: 1477831196
Provider Name (Legal Business Name): COREY J MCCANN CANP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD FL 3
LAKE CHARLES LA
70601-8990
US

IV. Provider business mailing address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-4900
  • Fax:
Mailing address:
  • Phone: 337-721-7236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP06636
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163WX0800X
TaxonomyOrthopedic Registered Nurse
License NumberRN114345
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: