Healthcare Provider Details

I. General information

NPI: 1649318957
Provider Name (Legal Business Name): DEBRA TOWER MALLETT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W MCNEESE ST
LAKE CHARLES LA
70605-5547
US

IV. Provider business mailing address

2724 RUE CALAIS DR
LAKE CHARLES LA
70605-4041
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-0511
  • Fax:
Mailing address:
  • Phone: 337-781-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN084146
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: