Provider Demographics
NPI:1679661615
Name:MOLBERT, BRANDY LAWSON (FNP)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LAWSON
Last Name:MOLBERT
Suffix:
Gender:F
Credentials:FNP
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 4176
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70361-4176
Mailing Address - Country:US
Mailing Address - Phone:985-876-0300
Mailing Address - Fax:985-872-0317
Practice Address - Street 1:520 N LEWIS ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70563-2094
Practice Address - Country:US
Practice Address - Phone:337-367-5200
Practice Address - Fax:337-369-3074
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN103097 - AP04768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00397581OtherRR MEDICARE
LA1317870Medicaid
LA4H701Medicare PIN
LAQ57447Medicare UPIN