Basic Information
| Provider Information | |||||||||
| NPI: | 1225276025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERSCH | ||||||||
| FirstName: | SHERI | ||||||||
| MiddleName: | WELLBORN | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | WELLBORN | ||||||||
| OtherFirstName: | SHERI | ||||||||
| OtherMiddleName: | KETCHUM | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1512 W KIRBY PL | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1501 KINGS HWY | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186755000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2009 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN077439 | LA | N | Nursing Service Providers | Registered Nurse | 363L00000X | AP03909 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1902128 | 05 | LA | MEDICAID | 3D091F600 | 01 | LA | MEDICARE - PTAN | OTHER |