Provider Demographics
NPI:1710961677
Name:PERRAULT, STACEY SMITH (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:SMITH
Last Name:PERRAULT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:LEIGH
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5339 DIDESSE DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4306
Mailing Address - Country:US
Mailing Address - Phone:225-765-3076
Mailing Address - Fax:225-765-3090
Practice Address - Street 1:5339 DIDESSE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4306
Practice Address - Country:US
Practice Address - Phone:225-765-3076
Practice Address - Fax:225-765-3090
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1478831Medicaid
LAP00251944OtherRAILROAD MEDICARE
LA4H352D279Medicare PIN
LA1478831Medicaid