Provider Demographics
NPI:1093090573
Name:KNIGHT, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:KNIGHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12447 FAWN WOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:LA
Mailing Address - Zip Code:70785-5754
Mailing Address - Country:US
Mailing Address - Phone:225-323-3475
Mailing Address - Fax:225-271-3877
Practice Address - Street 1:12447 FAWN WOOD DRIVE
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785-5754
Practice Address - Country:US
Practice Address - Phone:225-323-3475
Practice Address - Fax:225-272-3877
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA006582267172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2161636OtherMEDICAID PROVIDER #