Provider Demographics
NPI:1376057166
Name:MERRICKS, SHONATHAN EDWARD (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:SHONATHAN
Middle Name:EDWARD
Last Name:MERRICKS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43057 GREEN TREE AVE
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-8594
Mailing Address - Country:US
Mailing Address - Phone:504-701-4416
Mailing Address - Fax:504-298-0132
Practice Address - Street 1:43057 GREEN TREE AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-8594
Practice Address - Country:US
Practice Address - Phone:504-701-4416
Practice Address - Fax:504-298-0132
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA121585163W00000X
LA201571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse