Provider Demographics
NPI:1063426047
Name:PELLEGRIN, VIRGINIA M (NP)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:M
Last Name:PELLEGRIN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 DUNN ST
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4705
Mailing Address - Country:US
Mailing Address - Phone:985-876-1714
Mailing Address - Fax:985-868-6549
Practice Address - Street 1:509 DUNN ST
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4705
Practice Address - Country:US
Practice Address - Phone:985-876-1714
Practice Address - Fax:985-868-6549
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN086560363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1537667Medicaid
LA1537667Medicaid
LAP25214Medicare UPIN