Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | MD.022096 | LA |
NPI | 1104822782 |
---|---|
Provider Name | Dwan Shirmelle Mabry |
First Address | Hammond, LA 70403-1446 |
Second Address | Hammond, LA 70403-1446 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2005 |
Last Update Date | 19/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1491853 | (05) | LA |
G69782 | (02) | LA |