Provider Demographics
NPI:1598030009
Name:NETTERVILLE, LORI A (NP-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:NETTERVILLE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ASBURY CIR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3632
Mailing Address - Country:US
Mailing Address - Phone:225-663-0166
Mailing Address - Fax:337-983-2158
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06804363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2194399Medicaid
3D108CQ60Medicare PIN