Healthcare Provider Details

I. General information

NPI: 1871834556
Provider Name (Legal Business Name): JOHN ANDREW SHEALY H.I.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HUDSON LN
MONROE LA
71201-6045
US

IV. Provider business mailing address

2300 DESIREE ST
RUSTON LA
71270-7135
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-2363
  • Fax:
Mailing address:
  • Phone: 318-278-9557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1221
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: