Provider Demographics
NPI:1063796407
Name:MATHERS, MAREESA PERRAULT (FNP)
Entity type:Individual
Prefix:MRS
First Name:MAREESA
Middle Name:PERRAULT
Last Name:MATHERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MAREESA
Other - Middle Name:RENEE
Other - Last Name:PERRAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2390 W CONGRESS ST
Mailing Address - Street 2:ONCOLOGY DEPARTMENT, 5NORTH
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4205
Mailing Address - Country:US
Mailing Address - Phone:337-261-6515
Mailing Address - Fax:337-261-6555
Practice Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-5939
Practice Address - Country:US
Practice Address - Phone:337-988-1585
Practice Address - Fax:337-981-4694
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA06624363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2190261Medicaid
LA3D1136833Medicare PIN