Provider Demographics
NPI:1386925683
Name:DECLOUET, MARK (NP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DECLOUET
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 53709
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-3709
Mailing Address - Country:US
Mailing Address - Phone:877-294-7247
Mailing Address - Fax:337-210-3058
Practice Address - Street 1:315 AUDUBON BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2610
Practice Address - Country:US
Practice Address - Phone:337-522-7573
Practice Address - Fax:337-210-3058
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-31
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08202363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2386158Medicaid
LAPENDINGMedicare UPIN