Healthcare Provider Details

I. General information

NPI: 1144250606
Provider Name (Legal Business Name): DOUGLAS COUNCIL FNPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 MAIN ST
MARION LA
71260-5253
US

IV. Provider business mailing address

PO BOX 792
BASTROP LA
71221-0792
US

V. Phone/Fax

Practice location:
  • Phone: 318-283-8887
  • Fax:
Mailing address:
  • Phone: 318-283-8887
  • Fax: 318-281-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP03480
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP03480
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: