Provider Demographics
NPI:1255826897
Name:HARGRAVE, THRESA (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:THRESA
Middle Name:
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:THRESA
Other - Middle Name:A
Other - Last Name:MAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4415 SWAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6424
Mailing Address - Country:US
Mailing Address - Phone:318-780-5189
Mailing Address - Fax:
Practice Address - Street 1:2120 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3106
Practice Address - Country:US
Practice Address - Phone:318-688-3350
Practice Address - Fax:318-300-4439
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP10091363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health