Healthcare Provider Details

I. General information

NPI: 1689438764
Provider Name (Legal Business Name): MARY LYN DORE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CYPRESS ST
SULPHUR LA
70663-5052
US

IV. Provider business mailing address

2853 CHRISTY DR
LAKE CHARLES LA
70611-3658
US

V. Phone/Fax

Practice location:
  • Phone: 337-527-6371
  • Fax:
Mailing address:
  • Phone: 337-540-4963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number234472
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: