Healthcare Provider Details

I. General information

NPI: 1942549092
Provider Name (Legal Business Name): UNITED STATES AIRFORCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2013
Last Update Date: 02/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 N 5TH ST
MONROE LA
71201-4245
US

IV. Provider business mailing address

1801 N 5TH ST
MONROE LA
71201-4245
US

V. Phone/Fax

Practice location:
  • Phone: 318-235-9300
  • Fax:
Mailing address:
  • Phone: 318-235-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number119937
License Number StateLA

VIII. Authorized Official

Name: MRS. JESSICA HELEN MAHAN
Title or Position: NURSE PRACTITIONER
Credential: RN
Phone: 318-235-9300