Provider Demographics
NPI:1013416007
Name:TAYLOR, DAMETRA DANIELLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DAMETRA
Middle Name:DANIELLE
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JEFFERSON TER
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5727
Mailing Address - Country:US
Mailing Address - Phone:337-365-4945
Mailing Address - Fax:337-376-6860
Practice Address - Street 1:1050 N ROBINSON ST
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3536
Practice Address - Country:US
Practice Address - Phone:318-256-8150
Practice Address - Fax:318-256-8136
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09786363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2479521Medicaid