Healthcare Provider Details

I. General information

NPI: 1144838160
Provider Name (Legal Business Name): KIMBERLY MAYO POOL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1232 SHEPPARD ST
MINDEN LA
71055-3460
US

IV. Provider business mailing address

183 WELL SPRING RD
CALHOUN LA
71225-8540
US

V. Phone/Fax

Practice location:
  • Phone: 318-377-7116
  • Fax: 318-377-9979
Mailing address:
  • Phone: 318-235-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number213733
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: