Healthcare Provider Details

I. General information

NPI: 1255828398
Provider Name (Legal Business Name): PRIMARY CARE & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2018
Last Update Date: 04/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9954 LAKE FOREST BLVD STE 10
NEW ORLEANS LA
70127-2647
US

IV. Provider business mailing address

PO BOX 872713
NEW ORLEANS LA
70187-2713
US

V. Phone/Fax

Practice location:
  • Phone: 504-241-0105
  • Fax: 504-241-0106
Mailing address:
  • Phone: 404-490-0304
  • Fax: 504-241-0106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP09804
License Number StateLA

VIII. Authorized Official

Name: DARLENE LABOSTRIE
Title or Position: MANAGER
Credential:
Phone: 404-490-0304