Healthcare Provider Details

I. General information

NPI: 1770796161
Provider Name (Legal Business Name): YOUNGSVILLE MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 EAST MILTON AVENUE SUITE 1
YOUNGSVILLE LA
70592-5546
US

IV. Provider business mailing address

3215 EAST MILTON AVENUE SUITE 1
YOUNGSVILLE LA
70592
US

V. Phone/Fax

Practice location:
  • Phone: 337-857-2390
  • Fax: 337-857-2392
Mailing address:
  • Phone: 337-857-2390
  • Fax: 337-857-2392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP04512
License Number StateLA

VIII. Authorized Official

Name: MS. SHELLY NASH
Title or Position: OWNER
Credential: NP
Phone: 337-857-2390