Provider Demographics
NPI:1194263277
Name:CHURCH, RAINIE (LPN)
Entity type:Individual
Prefix:
First Name:RAINIE
Middle Name:
Last Name:CHURCH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:FARMERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71241-2311
Mailing Address - Country:US
Mailing Address - Phone:318-368-4755
Mailing Address - Fax:318-982-8050
Practice Address - Street 1:107 MILLER ST
Practice Address - Street 2:
Practice Address - City:FARMERVILLE
Practice Address - State:LA
Practice Address - Zip Code:71241
Practice Address - Country:US
Practice Address - Phone:318-368-4755
Practice Address - Fax:318-982-8050
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA990669164W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA474709560Medicaid