Healthcare Provider Details

I. General information

NPI: 1427450998
Provider Name (Legal Business Name): POLLY BUSH SMITH FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6925 HIGHWAY 74
SAINT GABRIEL LA
70776-4706
US

IV. Provider business mailing address

6925 HIGHWAY 74
SAINT GABRIEL LA
70776-4706
US

V. Phone/Fax

Practice location:
  • Phone: 225-642-3306
  • Fax: 225-319-4595
Mailing address:
  • Phone: 225-642-3306
  • Fax: 225-319-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP07914
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: