Healthcare Provider Details

I. General information

NPI: 1932409232
Provider Name (Legal Business Name): MEAGAN MARIE DISOTELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEAGAN STEPHAN DISOTELL NP

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY DEPARTMENT OF PEDIATRICS (NICU)
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1501 KINGS HWY DEPARTMENT OF PEDIATRICS (NICU)
SHREVEPORT LA
71103-4228
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-6073
  • Fax:
Mailing address:
  • Phone: 318-675-6073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPO6273
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: