Provider Demographics
NPI:1790383362
Name:HUMPHREY, DEXTER (HEALTH EDUCATOR)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:HEALTH EDUCATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 BREAZEALE SPRINGS ST
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-4278
Mailing Address - Country:US
Mailing Address - Phone:318-352-9299
Mailing Address - Fax:
Practice Address - Street 1:1640 BREAZEALE SPRINGS ST
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-4278
Practice Address - Country:US
Practice Address - Phone:318-352-9299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOMC-LC101174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator