Provider Demographics
NPI:1912080730
Name:MCDANIEL, MICA (NP)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:NP
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 276
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:LA
Mailing Address - Zip Code:70638-0276
Mailing Address - Country:US
Mailing Address - Phone:318-308-4447
Mailing Address - Fax:
Practice Address - Street 1:119 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:LA
Practice Address - Zip Code:71463-3034
Practice Address - Country:US
Practice Address - Phone:318-335-0260
Practice Address - Fax:318-335-3356
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA088334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1722201Medicaid
LAQ52393Medicare UPIN
LA4H632Medicare ID - Type Unspecified