Provider Demographics
NPI:1760954838
Name:POULAN, RONALD RICKEY
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:RICKEY
Last Name:POULAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-4206
Mailing Address - Country:US
Mailing Address - Phone:337-247-5248
Mailing Address - Fax:
Practice Address - Street 1:282 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-4206
Practice Address - Country:US
Practice Address - Phone:337-247-5248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-29
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty