Provider Demographics
NPI:1972763340
Name:HARRELL, NICOLE MATTHS (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MATTHS
Last Name:HARRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DAWNETTE
Other - Last Name:MATHIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5326 O'DONOVAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808
Mailing Address - Country:US
Mailing Address - Phone:225-769-7546
Mailing Address - Fax:225-769-0471
Practice Address - Street 1:5326 O'DOVAN DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:512-615-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2489207N00000X
390200000X
LAMD-202933207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1096199Medicaid
TX8DE581OtherBCBS
LA1096199Medicaid