1477706968 NPI number — EDNA BETH NETTLES PA-C

Table of content: EDNA BETH NETTLES PA-C (NPI 1477706968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477706968 NPI number — EDNA BETH NETTLES PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NETTLES
Provider First Name:
EDNA
Provider Middle Name:
BETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477706968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2706 HESSMER AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
METAIRIE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70002-7041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-754-2334
Provider Business Mailing Address Fax Number:
504-324-2078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2706 HESSMER AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
METAIRIE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70002-7041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
504-754-2334
Provider Business Practice Location Address Fax Number:
504-324-2078
Provider Enumeration Date:
10/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA1680 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA200705 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1509761 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1505839 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4211276 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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