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General NPI Number Information
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NPI Number | 1811209232
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Entity Type | Organization
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Legal Business Name | DESOTO HEALTHCARE CENTER INC.
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Dates
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Enumeration Date | 07/14/2010
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Last Update Date | 12/23/2011
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Provider Practice Location Address
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Address Line | 938 LOUISE ST
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City | MANSFIELD
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State | LA
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Zip | 71052
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Country | US
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Telephone | 318-871-1633
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Fax | 318-871-1677
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Provider Business Mailing Address
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Address Line | PO BOX 1384
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City | MANSFIELD
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State | LA
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Zip | 71052-1384
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Country | US
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Telephone | 318-871-1633
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Fax | 318-871-1677
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | MS. CONNIE B GANNON
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Credential | FNP
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Telephone | 318-871-1633
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 1487481
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 1996971
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 03124
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License Number State | LA
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 020173
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License Number State | LA
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Taxonomy #5
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD199935
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License Number State | LA
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