Provider Demographics
NPI:1821641374
Name:MOLLETTE, LATOSHA JACKSON (APRN)
Entity Type:Individual
Prefix:
First Name:LATOSHA
Middle Name:JACKSON
Last Name:MOLLETTE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 DAWSON ST
Mailing Address - Street 2:
Mailing Address - City:DUBACH
Mailing Address - State:LA
Mailing Address - Zip Code:71235-3201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 WATTS ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251-2053
Practice Address - Country:US
Practice Address - Phone:318-259-1569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily