Provider Demographics
NPI:1013266162
Name:PEZANT, WANDA LYNN (APRN)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LYNN
Last Name:PEZANT
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:PO BOX 395
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70722-0395
Mailing Address - Country:US
Mailing Address - Phone:225-683-5292
Mailing Address - Fax:225-683-3411
Practice Address - Street 1:3501 HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:LA
Practice Address - Zip Code:70748-6238
Practice Address - Country:US
Practice Address - Phone:225-683-5292
Practice Address - Fax:225-683-3411
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0812093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2318543Medicaid
LA2318543Medicaid