Basic Information
Provider Information | |||||||||
NPI: | 1205124310 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | LETARSHA | ||||||||
MiddleName: | ROULETTE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 80 EDWARD WELLS LN | ||||||||
Address2: |   | ||||||||
City: | GREENSBURG | ||||||||
State: | LA | ||||||||
PostalCode: | 704414081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2254055277 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11990 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | CLINTON | ||||||||
State: | LA | ||||||||
PostalCode: | 707223210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2256835292 | ||||||||
FaxNumber: | 2256831310 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2011 | ||||||||
LastUpdateDate: | 05/07/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/07/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APO6289 | LA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | AP06289 | LA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 2162748 | 05 | LA |   | MEDICAID |