Provider Demographics
NPI:1215067491
Name:NEWTON, LARESA VICTORIA (CRNP)
Entity type:Individual
Prefix:
First Name:LARESA
Middle Name:VICTORIA
Last Name:NEWTON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5803
Mailing Address - Country:US
Mailing Address - Phone:228-872-7605
Mailing Address - Fax:228-872-7627
Practice Address - Street 1:3890 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5803
Practice Address - Country:US
Practice Address - Phone:228-872-6291
Practice Address - Fax:228-872-7627
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874128363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07382051Medicaid