Healthcare Provider Details

I. General information

NPI: 1760583017
Provider Name (Legal Business Name): ANGELA S LETARD CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FRONT STREET
VIDALIA LA
71373
US

IV. Provider business mailing address

#12 RED FOX DRIVE
NATCHEZ MS
39120
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-2216
  • Fax: 318-336-6074
Mailing address:
  • Phone: 601-392-1471
  • Fax: 318-336-6074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN058840
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: