Healthcare Provider Details

I. General information

NPI: 1710161385
Provider Name (Legal Business Name): LALISA WADE FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 01/31/2023
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 CHISUM ST
SICILY ISLAND LA
71368-4807
US

IV. Provider business mailing address

PO BOX 8
SICILY ISLAND LA
71368-0008
US

V. Phone/Fax

Practice location:
  • Phone: 318-389-5727
  • Fax: 318-389-9943
Mailing address:
  • Phone: 318-389-5727
  • Fax: 318-389-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN101774
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP05320
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: