Basic Information
Provider Information | |||||||||
NPI: | 1003476144 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUNTER | ||||||||
FirstName: | KANDICE | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN, AGNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOHNSON-HUNTER | ||||||||
OtherFirstName: | KANDICE | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 116 SAVANNAH ST | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712023922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3185373056 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4864 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | MONROE | ||||||||
State: | LA | ||||||||
PostalCode: | 712026400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3183307000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2019 | ||||||||
LastUpdateDate: | 10/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 206498 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.