=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114681350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CYPRESS HEALTH AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2021
-----------------------------------------------------
Last Update Date | 10/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 327 IBERIA ST STE 3A
-----------------------------------------------------
City | YOUNGSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70592-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-230-4645
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 327 IBERIA ST STE 3A
-----------------------------------------------------
City | YOUNGSVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70592-6370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. JAIMIE VINCENT MELANCON
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 337-230-4645
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------