Individual
JUSTIN BOHANNAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
AG-ACNP
Contact information
Practice address
2770 3RD AVE STE 350, LAKE CHARLES, LA 70601-0404
(337) 494-2750
(337) 494-2760
Mailing address
PO BOX 122309 DEPT 2309, DALLAS, TX 75312-0001
(337) 494-2772
(337) 494-2928
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
219004
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
219004
STATE LICENSE
LA
05
—
2560891
—
LA
Enumeration date
06/07/2021
Last updated
02/03/2022
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