=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881722916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERTHA PAIGE MONIC RN058886
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2632 HIGHWAY 1
-----------------------------------------------------
City | LABADIEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70372-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-526-1699
-----------------------------------------------------
Fax | 985-526-6796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 CAVANESS DR
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70364-2201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-872-0790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN058886
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------