Provider Demographics
NPI:1477585040
Name:TALBERT, MARY LOUISE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LOUISE
Last Name:TALBERT
Suffix:
Gender:F
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 580
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70602-0580
Mailing Address - Country:US
Mailing Address - Phone:337-439-2119
Mailing Address - Fax:337-439-2120
Practice Address - Street 1:1011 LAKE SHORE DR
Practice Address - Street 2:STE. 522
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-9412
Practice Address - Country:US
Practice Address - Phone:337-439-2119
Practice Address - Fax:337-439-2120
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2921-302-571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2921-302-571OtherNATIONAL CERT. COD. SPEC.