=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255811659
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGNIAPPE MEDICAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2018
-----------------------------------------------------
Last Update Date | 08/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 GREENBRIER BLVD
-----------------------------------------------------
City | COVINGTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70433-7236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-771-2221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 957
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70447-0957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-771-2221
-----------------------------------------------------
Fax | 844-713-8349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ATNENA LUSTER
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 985-771-2221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RX0202X
-----------------------------------------------------
Taxonomy Name | Medical Oncology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------