Provider Demographics
NPI:1154652618
Name:ADVANCED DERMATOLOGY & FAMILY HEALTH CARE WALK-IN & WELLNESS CLINICLLC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY & FAMILY HEALTH CARE WALK-IN & WELLNESS CLINICLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT NURSE PRACTITIONER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:ANP-C
Authorized Official - Phone:985-674-4015
Mailing Address - Street 1:3295 E CAUSEWAY APPROACH
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-3451
Mailing Address - Country:US
Mailing Address - Phone:985-674-1481
Mailing Address - Fax:985-626-6956
Practice Address - Street 1:3295 E CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3451
Practice Address - Country:US
Practice Address - Phone:985-674-1481
Practice Address - Fax:985-626-6956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05770363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1812226Medicaid
LA1812226Medicaid