Provider Demographics
NPI:1457426348
Name:FAUTHEREE, ALICE JO (APRN, BC, FNP)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:JO
Last Name:FAUTHEREE
Suffix:
Gender:F
Credentials:APRN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 DOWNEY LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-4746
Mailing Address - Country:US
Mailing Address - Phone:318-322-1732
Mailing Address - Fax:
Practice Address - Street 1:1140 UNIVERSITY AVE., MONROE, LA 71209-1170 3183421651
Practice Address - Street 2:2110 JUSTICE STREET
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-322-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45485-01456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1684252Medicaid
LAS37303Medicare UPIN
LA1684252Medicaid