MEDICARE: NEBRA KANIVBREYA LOSTON

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1225660723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEBRA KANIVBREYA LOSTON

Provider Business Mailing Address
First Line	:	100 A B MARTIN RD
Second Line	:
City	:	JEANERETTE
State	:	LA
Zip	:	70544-8701
Country	:	US
Telephone Number	:	337-579-0971
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 A B MARTIN RD
Second Line	:
City	:	JEANERETTE
State	:	LA
Zip	:	70544-8701
Country	:	US
Telephone Number	:	337-579-0971
Fax Number	:

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

Provider Enumeration Date	:	02/12/2020
Last Update Date	:	02/12/2020

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