Healthcare Provider Details

I. General information

NPI: 1063046662
Provider Name (Legal Business Name): COURTNEY LYNN THOMAS APRN NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W GAUTHIER RD
LAKE CHARLES LA
70605-7170
US

IV. Provider business mailing address

5800 DUNDEE ST
LAKE CHARLES LA
70605-7128
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-7050
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number204336
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: