MEDICARE: DR. FLEETWOOD LOUSTALOT III RN, NP-C, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R864143	MS
2	363LF0000X	Family Nurse Practitioner	RN206938	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	206938	OTHER	GA	LICENSE
2	R864143	OTHER	MS	LICENSE NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164470928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FLEETWOOD LOUSTALOT III RN, NP-C, PHD

Provider Business Mailing Address
First Line	:	2 LAKEVIEW CV
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-8528
Country	:	US
Telephone Number	:	601-264-2657
Fax Number	:

Provider Business Practice Location Address
First Line	:	4770 BUFORD HWY
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-3717
Country	:	US
Telephone Number	:	770-488-5198
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	10/09/2025

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