Healthcare Provider Details

I. General information

NPI: 1497357156
Provider Name (Legal Business Name): DRW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 11/16/2020
Certification Date: 11/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

832 JULIA ST
RAYVILLE LA
71269-2608
US

IV. Provider business mailing address

PO BOX 15581
MONROE LA
71207-5581
US

V. Phone/Fax

Practice location:
  • Phone: 318-728-4787
  • Fax: 318-728-2598
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRITTNEY WHITLOCK
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 318-325-6200