Basic Information
| Provider Information | |||||||||
| NPI: | 1083232771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 DESIARD ST STE 355 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712017363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3188077875 | ||||||||
| FaxNumber: | 3188126603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 UNIVERSITY AVENUE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712095702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183421651 | ||||||||
| FaxNumber: | 3183423280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 213927 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.