Healthcare Provider Details

I. General information

NPI: 1184823676
Provider Name (Legal Business Name): JOHN R MASSEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 BELUE LANE SUITE B
RUSTON LA
71270-5936
US

IV. Provider business mailing address

604 BELUE LANE SUITE B
RUSTON LA
71270-8299
US

V. Phone/Fax

Practice location:
  • Phone: 318-251-6385
  • Fax:
Mailing address:
  • Phone: 318-251-6385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number1660
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: