Provider Demographics
NPI:1295398808
Name:MAGGIO, NICHOLAS GLEN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:GLEN
Last Name:MAGGIO
Suffix:
Gender:M
Credentials:
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 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-2529
Mailing Address - Fax:225-683-1310
Practice Address - Street 1:11990 JACKSON ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:LA
Practice Address - Zip Code:70722-3210
Practice Address - Country:US
Practice Address - Phone:225-683-5292
Practice Address - Fax:225-683-1310
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily