Healthcare Provider Details

I. General information

NPI: 1295612679
Provider Name (Legal Business Name): CRISTY S GREMILLION RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 03/22/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43672 HIGHWAY 16
PINE GROVE LA
70453-2102
US

IV. Provider business mailing address

43672 HIGHWAY 16
PINE GROVE LA
70453-2102
US

V. Phone/Fax

Practice location:
  • Phone: 225-362-8287
  • Fax:
Mailing address:
  • Phone: 225-362-8287
  • Fax: 225-362-8287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number245170
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: