Healthcare Provider Details

I. General information

NPI: 1679612634
Provider Name (Legal Business Name): MS. DEWANA BOBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5326 OAK ST.
ST. FRANCISVILLE LA
70775
US

IV. Provider business mailing address

PO BOX 487
SAINT FRANCISVILLE LA
70775-0487
US

V. Phone/Fax

Practice location:
  • Phone: 225-635-5848
  • Fax:
Mailing address:
  • Phone: 225-635-5848
  • Fax: 225-635-5847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP03925
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: