Individual
MARY MANCUSO HEAROD
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
N.P.
Contact information
Practice address
2770 3RD AVE STE 345, LAKE CHARLES, LA 70601-8994
(337) 494-4785
(337) 494-4786
Mailing address
PO BOX 122623, DEPT 2623, DALLAS, TX 75312-2623
(337) 494-2921
(337) 494-6523
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
AP09122
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2439740
—
LA
01
—
AP09122
STATE MEDICAL LICENSE
LA
Enumeration date
03/06/2017
Last updated
04/27/2022
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