Healthcare Provider Details

I. General information

NPI: 1871108357
Provider Name (Legal Business Name): CHARETTE DELLAGATTA RN, CCRP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1449 E BERT KOUN LOOP STE 102
SHREVEPORT LA
71105-5663
US

IV. Provider business mailing address

6021 DILLINGHAM AVE
SHREVEPORT LA
71106-2109
US

V. Phone/Fax

Practice location:
  • Phone: 318-681-5353
  • Fax: 318-681-6305
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC3500X
TaxonomyCardiac Rehabilitation Registered Nurse
License NumberRN148778
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN148778
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: