Provider Demographics
NPI:1194945360
Name:BALL, REPUNDA MIMS
Entity type:Individual
Prefix:
First Name:REPUNDA
Middle Name:MIMS
Last Name:BALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 PINES RD STE.1104
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129
Mailing Address - Country:US
Mailing Address - Phone:318-671-1772
Mailing Address - Fax:318-671-1774
Practice Address - Street 1:7505 PINES RD STE 1104
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-3900
Practice Address - Country:US
Practice Address - Phone:318-671-1772
Practice Address - Fax:318-671-1774
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10737372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1172057Medicaid
LA1542946Medicaid
LA1178969Medicaid
LA1545180Medicaid