Healthcare Provider Details

I. General information

NPI: 1609390327
Provider Name (Legal Business Name): JERELYN CARPENTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 SHREVEPORT HWY
PINEVILLE LA
71360-4044
US

IV. Provider business mailing address

1920 BRENTWOOD AVE
ALEXANDRIA LA
71301-3801
US

V. Phone/Fax

Practice location:
  • Phone: 318-473-0010
  • Fax:
Mailing address:
  • Phone: 337-424-3253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number123733
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: