Provider Demographics
NPI:1740622638
Name:RABALAIS, MARY DIANE (WHNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DIANE
Last Name:RABALAIS
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2668
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2668
Mailing Address - Country:US
Mailing Address - Phone:985-230-7650
Mailing Address - Fax:985-230-7655
Practice Address - Street 1:15813 PAUL VEGA MD DR STE 200
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1431
Practice Address - Country:US
Practice Address - Phone:985-230-7650
Practice Address - Fax:985-230-7655
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07283363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03976556Medicaid
LA2374125Medicaid
LA369580YH3UMedicare PIN