Provider Demographics
NPI:1760583017
Name:LETARD, ANGELA S (CFNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:S
Last Name:LETARD
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#12 RED FOX DRIVE
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120
Mailing Address - Country:US
Mailing Address - Phone:601-392-1471
Mailing Address - Fax:318-336-6074
Practice Address - Street 1:107 FRONT STREET
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373
Practice Address - Country:US
Practice Address - Phone:318-336-2216
Practice Address - Fax:318-336-6074
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN058840363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1181196Medicaid
MS0123703Medicaid
P28266Medicare PIN
LA1181196Medicaid