Provider Demographics
NPI:1174819668
Name:HOMER, DANA BETH (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:BETH
Last Name:HOMER
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:BETH
Other - Last Name:FONTENOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN FNP
Mailing Address - Street 1:1587 N BOLTON AVE
Mailing Address - Street 2:STE 1100
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-4255
Mailing Address - Country:US
Mailing Address - Phone:318-709-9051
Mailing Address - Fax:318-445-1509
Practice Address - Street 1:1587 N BOLTON AVE
Practice Address - Street 2:STE 1100
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-4255
Practice Address - Country:US
Practice Address - Phone:318-709-9051
Practice Address - Fax:318-445-1509
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN112634-AP06478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2155822Medicaid
LA2155822Medicaid