Healthcare Provider Details

I. General information

NPI: 1396051868
Provider Name (Legal Business Name): MICHELLE MARIE CIVELLO N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28050 WALKER SOUTH RD
WALKER LA
70785-6047
US

IV. Provider business mailing address

28050 WALKER SOUTH RD
WALKER LA
70785-6047
US

V. Phone/Fax

Practice location:
  • Phone: 225-664-2111
  • Fax: 225-664-2888
Mailing address:
  • Phone: 225-664-2111
  • Fax: 225-664-2888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP06133
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: