Provider Demographics
NPI:1164470928
Name:LOUSTALOT, FLEETWOOD III (RN, NP-C, PHD)
Entity type:Individual
Prefix:DR
First Name:FLEETWOOD
Middle Name:
Last Name:LOUSTALOT
Suffix:III
Gender:M
Credentials:RN, NP-C, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LAKEVIEW CV
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8528
Mailing Address - Country:US
Mailing Address - Phone:601-264-2657
Mailing Address - Fax:
Practice Address - Street 1:4770 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-3717
Practice Address - Country:US
Practice Address - Phone:770-488-5198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR864143363LF0000X
GARN206938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA206938OtherLICENSE
MSR864143OtherLICENSE NUMBER
MS0126734Medicaid