Provider Demographics
NPI:1356759153
Name:ACOSTA, MARY TILLMAN (WHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:TILLMAN
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8001 YOUREE DR STE 320
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-2354
Mailing Address - Country:US
Mailing Address - Phone:318-212-2870
Mailing Address - Fax:318-212-2875
Practice Address - Street 1:8001 YOUREE DR STE 300
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2303
Practice Address - Country:US
Practice Address - Phone:318-212-3800
Practice Address - Fax:318-212-3805
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07973363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health