=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578979852
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA GAUDET ESTAY FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2014
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 NW CENTRAL AVE
-----------------------------------------------------
City | AMITE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70422-2428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-748-7141
-----------------------------------------------------
Fax | 985-748-3181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5088 TANGLEWOOD RD
-----------------------------------------------------
City | MCCOMB
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39648-8273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-992-6777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP07938
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------