Healthcare Provider Details

I. General information

NPI: 1174468995
Provider Name (Legal Business Name): MADISON THERIOT LESTAGE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 HORRIDGE ST
VINTON LA
70668-4531
US

IV. Provider business mailing address

212 ORCHARD DR
LAKE CHARLES LA
70605-4444
US

V. Phone/Fax

Practice location:
  • Phone: 337-324-8060
  • Fax:
Mailing address:
  • Phone: 337-965-6984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number206785
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: