Provider Demographics
NPI:1417143249
Name:AUTHEMENT, LISA RUSSO (MSN-APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RUSSO
Last Name:AUTHEMENT
Suffix:
Gender:F
Credentials:MSN-APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 VERRET ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4637
Mailing Address - Country:US
Mailing Address - Phone:985-876-7388
Mailing Address - Fax:985-872-2878
Practice Address - Street 1:911 VERRET ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4637
Practice Address - Country:US
Practice Address - Phone:985-876-7388
Practice Address - Fax:985-872-2878
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05301363LF0000X
LARN078449163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1030431Medicaid
LA3A4035F669Medicare PIN