Provider Demographics
NPI:1659300143
Name:GAUDIN, MARY BETH (CANP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:GAUDIN
Suffix:
Gender:F
Credentials:CANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 SOUTH GATE
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454
Mailing Address - Country:US
Mailing Address - Phone:985-542-6251
Mailing Address - Fax:
Practice Address - Street 1:42388 PELICAN PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:985-542-6251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03655363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP03655OtherSTATE LICENSE #
LA30051OtherLA CONTROL #
LA1495948Medicaid
LA1495948Medicaid
LA4B560CB03Medicare ID - Type UnspecifiedMEDICARE
LA30051OtherLA CONTROL #