Healthcare Provider Details

I. General information

NPI: 1366811697
Provider Name (Legal Business Name): DONNA BARTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 CADDO STEET
MONTGOMERY LA
71454-0271
US

IV. Provider business mailing address

1101 CADDO STEET
MONTGOMERY LA
71454-0271
US

V. Phone/Fax

Practice location:
  • Phone: 318-646-4025
  • Fax: 318-646-4026
Mailing address:
  • Phone: 318-646-4025
  • Fax: 318-646-4026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number057918
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: