Healthcare Provider Details

I. General information

NPI: 1699746487
Provider Name (Legal Business Name): KENNETH ALLAN EBERSOLE APRN,FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 337-217-7762
  • Fax: 337-855-5310
Mailing address:
  • Phone: 337-312-8258
  • Fax: 337-312-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP03160
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: