Healthcare Provider Details

I. General information

NPI: 1235196254
Provider Name (Legal Business Name): SKIPPER K STEWART APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14292 FLORIDA BLVD
LIVINGSTON LA
70754
US

IV. Provider business mailing address

PO BOX 1573 21098 OAK ALLEY DRIVE
LIVINGSTON LA
70754-6310
US

V. Phone/Fax

Practice location:
  • Phone: 225-686-1114
  • Fax:
Mailing address:
  • Phone: 225-686-1244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04734
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: