Provider Demographics
NPI:1407087034
Name:BOOTH, SHANI GORIO (ANP, PMHNP)
Entity type:Individual
Prefix:
First Name:SHANI
Middle Name:GORIO
Last Name:BOOTH
Suffix:
Gender:F
Credentials:ANP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 OX BOW LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7273
Mailing Address - Country:US
Mailing Address - Phone:985-507-8436
Mailing Address - Fax:
Practice Address - Street 1:42334 DELUXE PLZ STE 2
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1237
Practice Address - Country:US
Practice Address - Phone:985-662-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05920363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1803634Medicaid
LAP00830859OtherMEDICARE RAILROAD
LAD06873OtherMEDICARE RAILROAD GROUP
LA3B287Medicare PIN