Provider Demographics
NPI:1225565807
Name:MALLARD, LATRICE SHONTA (MAM, APRN, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LATRICE
Middle Name:SHONTA
Last Name:MALLARD
Suffix:
Gender:F
Credentials:MAM, APRN, PMHNP-BC
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 40984
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70835-0984
Mailing Address - Country:US
Mailing Address - Phone:225-315-1357
Mailing Address - Fax:
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:225-315-1357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-15
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA117290163WP0808X
LA229471363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid