Provider Demographics
NPI:1649579251
Name:STANSBURY, AUDREY BON (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:BON
Last Name:STANSBURY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9049 SMOKE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-6962
Mailing Address - Country:US
Mailing Address - Phone:225-247-3491
Mailing Address - Fax:
Practice Address - Street 1:5760 MONTICELLO DR
Practice Address - Street 2:
Practice Address - City:SAINT GABRIEL
Practice Address - State:LA
Practice Address - Zip Code:70776-4412
Practice Address - Country:US
Practice Address - Phone:225-247-3491
Practice Address - Fax:225-756-5335
Is Sole Proprietor?:No
Enumeration Date:2011-03-22
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN06788-AP06419363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2147684Medicaid
LA3C463C822Medicare PIN