Provider Demographics
NPI:1780237701
Name:INMAN, MARY (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:INMAN
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 E BERT KOUN LOOP STE 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5680
Mailing Address - Country:US
Mailing Address - Phone:318-629-0220
Mailing Address - Fax:318-629-0230
Practice Address - Street 1:1449 E BERT KOUN LOOP STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5680
Practice Address - Country:US
Practice Address - Phone:318-629-0220
Practice Address - Fax:318-629-0230
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA207290363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology