Healthcare Provider Details

I. General information

NPI: 1902207228
Provider Name (Legal Business Name): ISHA JUANELLE LANG NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ISHA JUANELLE WILTZ RN

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 07/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALTERS ST
LAKE CHARLES LA
70607-4647
US

IV. Provider business mailing address

4345 NELSON RD
LAKE CHARLES LA
70605-4119
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-3209
  • Fax:
Mailing address:
  • Phone: 337-480-3209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07953
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: