Healthcare Provider Details

I. General information

NPI: 1134337017
Provider Name (Legal Business Name): ELLENDALE WITHERS GABBERT C-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

IV. Provider business mailing address

501 DR MICHAEL DEBAKEY DR
LAKE CHARLES LA
70601-5724
US

V. Phone/Fax

Practice location:
  • Phone: 337-433-8400
  • Fax: 337-312-6711
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number63422-3267
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: