Provider Demographics
NPI:1174166748
Name:PROVOST, GAIL JONES
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:JONES
Last Name:PROVOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7730 WINDWARD CT
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70128-1339
Mailing Address - Country:US
Mailing Address - Phone:504-237-2189
Mailing Address - Fax:504-241-1649
Practice Address - Street 1:9954 LAKE FOREST BLVD STE 5
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-5498
Practice Address - Country:US
Practice Address - Phone:504-237-2189
Practice Address - Fax:504-241-1649
Is Sole Proprietor?:No
Enumeration Date:2019-10-25
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
LA246RM2200X, 247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory