Provider Demographics
NPI:1811209232
Name:DESOTO HEALTHCARE CENTER INC.
Entity type:Organization
Organization Name:DESOTO HEALTHCARE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:GANNON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:318-871-1633
Mailing Address - Street 1:PO BOX 1384
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052-1384
Mailing Address - Country:US
Mailing Address - Phone:318-871-1633
Mailing Address - Fax:318-871-1677
Practice Address - Street 1:938 LOUISE ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052
Practice Address - Country:US
Practice Address - Phone:318-871-1633
Practice Address - Fax:318-871-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-14
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1487481207RN0300X
LA1996971208000000X
LA03124363LF0000X
LA020173363LF0000X
LAMD199935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2117629Medicaid
LA5DQ44Medicare PIN