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General NPI Number Information
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NPI Number | 1164470928
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Entity Type | Individual
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Provider Name | FLEETWOOD LOUSTALOT III RN, NP-C, PHD
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Gender | Male
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Dates
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Enumeration Date | 05/04/2006
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Last Update Date | 10/09/2025
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Provider Practice Location Address
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Address Line | 4770 BUFORD HWY
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City | ATLANTA
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State | GA
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Zip | 30341-3717
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Country | US
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Telephone | 770-488-5198
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Fax |
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Provider Business Mailing Address
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Address Line | 2 LAKEVIEW CV
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City | HATTIESBURG
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State | MS
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Zip | 39402-8528
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Country | US
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Telephone | 601-264-2657
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R864143
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN206938
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License Number State | GA
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