Provider Demographics
NPI:1134160815
Name:PELLEGRIN, TIMOTHY J (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:PELLEGRIN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 WEBER ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:LA
Mailing Address - Zip Code:70538-4124
Mailing Address - Country:US
Mailing Address - Phone:337-828-2550
Mailing Address - Fax:337-355-2335
Practice Address - Street 1:1014 W TUNNEL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4050
Practice Address - Country:US
Practice Address - Phone:985-851-1717
Practice Address - Fax:985-868-3839
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO4222363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C669OtherMEDICARE NUMBER
LA1152919Medicaid
LA568555OtherMEDICARE
4C669Medicare ID - Type UnspecifiedPART B PROVIDER NUMBER