Healthcare Provider Details

I. General information

NPI: 1417168519
Provider Name (Legal Business Name): NICOLE LATOUR GASPARD RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 E MAIN ST
NEW IBERIA LA
70560-4031
US

IV. Provider business mailing address

6604 FREMIN RD
NEW IBERIA LA
70560-9149
US

V. Phone/Fax

Practice location:
  • Phone: 337-364-0441
  • Fax:
Mailing address:
  • Phone: 337-364-0441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number1402
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: