Provider Demographics
NPI:1093107310
Name:PEARL, NIKITA
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:PEARL
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:PO BOX 770
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0770
Mailing Address - Country:US
Mailing Address - Phone:888-414-7247
Mailing Address - Fax:225-658-1282
Practice Address - Street 1:721 AVENUE G
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:LA
Practice Address - Zip Code:70444-2601
Practice Address - Country:US
Practice Address - Phone:888-414-7247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily