=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629912936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVID HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2026
-----------------------------------------------------
Last Update Date | 04/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 NEWSOM DRVE
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-228-6072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 NEWSOM DRVE
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-228-6072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FNP-C
-----------------------------------------------------
Name | KIMBERLIE LA'TASHA MABRY
-----------------------------------------------------
Credential | FNP-C
-----------------------------------------------------
Telephone | 228-627-1223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------