Healthcare Provider Details

I. General information

NPI: 1023014313
Provider Name (Legal Business Name): MAUREEN ROSE LANNAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 CYPRESS ST
SULPHUR LA
70663-5052
US

IV. Provider business mailing address

5204 LA PAIX DR
SULPHUR LA
70665-9369
US

V. Phone/Fax

Practice location:
  • Phone: 337-527-2491
  • Fax: 337-528-2749
Mailing address:
  • Phone: 337-583-9530
  • Fax: 337-528-2749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10386R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: