| Organization Name: | PSYCHIATRIC NURSE PRACTITIONER SERVICES, LLC |
| NPI Number: | 1043601685 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SUSAN MARIE DERIVAS (PSYCHIATIRC NURSE PRACTITIONER) |
| Mailing Address: | 2208 Kiber St Shreveport |
| State: | LA US |
| Postal Code: | 711042045 |
| Phone Number: | 3185605883 |
| Fax Number: | 3186171590 |
| NPI Enumeration Date: | 02/17/2015 |
| NPI Last Update Date: | 02/17/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0808X |
| License Number: | RN79944 AP3962 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | LA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Psych/Mental Health |
| Taxonomy Definition: | |