Healthcare Provider Details

I. General information

NPI: 1275900029
Provider Name (Legal Business Name): MAYA SHANNON ROLLINS CCMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WILKINSON ST
MANDEVILLE LA
70448-3533
US

IV. Provider business mailing address

37203 WEST TIMBERLINE DRIVE
SLIDELL LA
70460
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-4450
  • Fax: 985-624-4461
Mailing address:
  • Phone: 504-252-1182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberW6R8Q5D7
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License NumberY4X2G3P6
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberZ3D8D5E5
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: