Provider Demographics
NPI:1982196432
Name:WILSON, DONNA BOUDREAUX
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:BOUDREAUX
Last Name:WILSON
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 1:978 BULL RUN RD
Mailing Address - Street 2:
Mailing Address - City:SCHRIEVER
Mailing Address - State:LA
Mailing Address - Zip Code:70395-3216
Mailing Address - Country:US
Mailing Address - Phone:985-217-7873
Mailing Address - Fax:
Practice Address - Street 1:1125 MARGUERITE ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1855
Practice Address - Country:US
Practice Address - Phone:985-384-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily