Provider Demographics
NPI:1265769798
Name:RACCA, MARIEL J (NP-C)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:J
Last Name:RACCA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARIEL
Other - Middle Name:J
Other - Last Name:RACCA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:2110 STANTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7212
Mailing Address - Country:US
Mailing Address - Phone:337-433-8113
Mailing Address - Fax:
Practice Address - Street 1:2000 OPELOUSAS ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2641
Practice Address - Country:US
Practice Address - Phone:337-493-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAF1009130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1265769798Medicaid