Provider Demographics
NPI:1053705574
Name:WELLNESS CENTER FOR SKIN THERAPY LLC
Entity type:Organization
Organization Name:WELLNESS CENTER FOR SKIN THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BURNS
Authorized Official - Last Name:NORWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:318-636-9905
Mailing Address - Street 1:2751 ALBERT L BICKNELL DR
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3920
Mailing Address - Country:US
Mailing Address - Phone:318-636-9905
Mailing Address - Fax:
Practice Address - Street 1:2751 ALBERT L BICKNELL DR
Practice Address - Street 2:SUITE 1A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3920
Practice Address - Country:US
Practice Address - Phone:318-221-2821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03173363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty