Provider Demographics
NPI:1326676792
Name:DIVINITY HEALTHCARE CLINIC
Entity Type:Organization
Organization Name:DIVINITY HEALTHCARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELANCON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:225-301-2982
Mailing Address - Street 1:11515 DENHAM RD
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-7787
Mailing Address - Country:US
Mailing Address - Phone:225-301-2982
Mailing Address - Fax:
Practice Address - Street 1:4021 WE HECK CT STE B1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-0405
Practice Address - Country:US
Practice Address - Phone:225-256-7945
Practice Address - Fax:225-351-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-31
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty