Provider Demographics
NPI:1962116269
Name:MENARD, EBONY PAIGE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:PAIGE
Last Name:MENARD
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 1:604 DEER MEADOW BLVD
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-5232
Mailing Address - Country:US
Mailing Address - Phone:337-366-5370
Mailing Address - Fax:
Practice Address - Street 1:106 HEYMANN BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2322
Practice Address - Country:US
Practice Address - Phone:337-366-5370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20130925164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse