Provider Demographics
NPI:1174609721
Name:COUNCIL FOR THE ADVANCEMENT OF SOCIAL SERVICES AND EDUCATION
Entity type:Organization
Organization Name:COUNCIL FOR THE ADVANCEMENT OF SOCIAL SERVICES AND EDUCATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:318-872-1015
Mailing Address - Street 1:907 POLK ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-2520
Mailing Address - Country:US
Mailing Address - Phone:318-872-1015
Mailing Address - Fax:318-872-1055
Practice Address - Street 1:907 POLK ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052-2520
Practice Address - Country:US
Practice Address - Phone:318-872-1015
Practice Address - Fax:318-872-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1452769Medicaid
LA1452769Medicaid