Healthcare Provider Details

I. General information

NPI: 1073704391
Provider Name (Legal Business Name): LORETTA PYLANT GREMILLION M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 06/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 BROADMOOR BLVD
MONROE LA
71201-2964
US

IV. Provider business mailing address

1868 FORSYTHE AVE STE 335
MONROE LA
71201-3540
US

V. Phone/Fax

Practice location:
  • Phone: 318-323-8799
  • Fax: 318-323-8815
Mailing address:
  • Phone: 318-251-6216
  • Fax: 318-251-6257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number026501
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: