Provider Demographics
NPI:1770796161
Name:YOUNGSVILLE MEDICAL LLC
Entity type:Organization
Organization Name:YOUNGSVILLE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:NASH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:337-857-2390
Mailing Address - Street 1:3215 EAST MILTON AVENUE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592
Mailing Address - Country:US
Mailing Address - Phone:337-857-2390
Mailing Address - Fax:337-857-2392
Practice Address - Street 1:3215 EAST MILTON AVENUE SUITE 1
Practice Address - Street 2:
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5546
Practice Address - Country:US
Practice Address - Phone:337-857-2390
Practice Address - Fax:337-857-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAQ34422Medicare UPIN
LA5CY63Medicare PIN