Provider Demographics
NPI:1225229552
Name:PROSPERIE, NICOLE D (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:PROSPERIE
Suffix:
Gender:F
Credentials:MD
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 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-448-1216
Mailing Address - Fax:985-446-8765
Practice Address - Street 1:506 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4862
Practice Address - Country:US
Practice Address - Phone:985-448-1216
Practice Address - Fax:985-446-8765
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD203822207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1000965Medicaid
LAP01534049OtherRAILROAD MEDICARE
LAP01534049OtherRAILROAD MEDICARE