Provider Demographics
NPI:1124360144
Name:DALE TATE FNP LLC
Entity Type:Organization
Organization Name:DALE TATE FNP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:TATE
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP
Authorized Official - Phone:985-229-4114
Mailing Address - Street 1:75136 N RIVER RD
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:LA
Mailing Address - Zip Code:70444-3800
Mailing Address - Country:US
Mailing Address - Phone:985-229-4114
Mailing Address - Fax:
Practice Address - Street 1:75136 N RIVER RD
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:LA
Practice Address - Zip Code:70444-3800
Practice Address - Country:US
Practice Address - Phone:985-229-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN102323/AP06135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2115014Medicaid
LA2115014Medicaid