Healthcare Provider Details

I. General information

NPI: 1184234114
Provider Name (Legal Business Name): JANET HULLABY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3577 LAKESIDE DR
SHREVEPORT LA
71119-6515
US

IV. Provider business mailing address

3577 LAKESIDE DR
SHREVEPORT LA
71119-6515
US

V. Phone/Fax

Practice location:
  • Phone: 318-455-3199
  • Fax:
Mailing address:
  • Phone: 318-455-3199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: