Basic Information
| Provider Information | |||||||||
| NPI: | 1144673344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETWILER | ||||||||
| FirstName: | JANCI | ||||||||
| MiddleName: | BIENVENU | ||||||||
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| Credential: | CPNP-PC/AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 BURLINGTON CIR | ||||||||
| Address2: | |||||||||
| City: | BROUSSARD | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705187414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372242123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4801 AMBASSADOR CAFFERY PKWY | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374702017 | ||||||||
| FaxNumber: | 3374702809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2016 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0222X | AP08962 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care | 363LP0200X | AP08962 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | AP08962 | 01 | LA | STATE LICENSE | OTHER |