Provider Demographics
NPI:1790169928
Name:PROCTOR, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 LOUIS PRIMA DR
Mailing Address - Street 2:STE A
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-5903
Mailing Address - Country:US
Mailing Address - Phone:985-892-7070
Mailing Address - Fax:985-892-7017
Practice Address - Street 1:3975 I-49 FRONTAGE ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-9999
Practice Address - Country:US
Practice Address - Phone:337-594-0750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily