Healthcare Provider Details

I. General information

NPI: 1912742990
Provider Name (Legal Business Name): STEPHANIE GILLS HUMPHREY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MEDICAL PLAZA PL
MINDEN LA
71055-3330
US

IV. Provider business mailing address

215 MAIN ST
MINDEN LA
71055-3322
US

V. Phone/Fax

Practice location:
  • Phone: 318-371-4042
  • Fax:
Mailing address:
  • Phone: 318-505-4932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number236213
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number236213
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: