Provider Demographics
NPI:1932781747
Name:DARBONNE, MARY SAMANTHA (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SAMANTHA
Last Name:DARBONNE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4865 KINGSPOINT DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5985
Mailing Address - Country:US
Mailing Address - Phone:337-474-9756
Mailing Address - Fax:
Practice Address - Street 1:2000 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4181
Practice Address - Country:US
Practice Address - Phone:337-474-2856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA219390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2581767Medicaid