Basic Information
| Provider Information | |||||||||
| NPI: | 1881796860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANUEL | ||||||||
| FirstName: | LORETTA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 10TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706016027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374295087 | ||||||||
| FaxNumber: | 5753960318 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 10TH ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706016027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374295087 | ||||||||
| FaxNumber: | 5753960318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 08/19/2013 | ||||||||
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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 | 367500000X | 735519 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 735519 | 01 | TX | BOARD OF NURSING | OTHER |