=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396388252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS DEIDRA NERVE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2019
-----------------------------------------------------
Last Update Date | 10/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 TALBOT ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70538-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-255-6090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 TALBOT ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70538-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 337-255-6090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 290995
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------