Provider Demographics
NPI:1902207228
Name:LANG, ISHA JUANELLE (NP-C)
Entity Type:Individual
Prefix:MISS
First Name:ISHA
Middle Name:JUANELLE
Last Name:LANG
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MRS
Other - First Name:ISHA
Other - Middle Name:JUANELLE
Other - Last Name:WILTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4345 NELSON RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4119
Mailing Address - Country:US
Mailing Address - Phone:337-480-3209
Mailing Address - Fax:
Practice Address - Street 1:1000 WALTERS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-4647
Practice Address - Country:US
Practice Address - Phone:337-480-3209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LAAP07953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171M00000XOther Service ProvidersCase Manager/Care Coordinator