Provider Demographics
NPI:1144673344
Name:DETWILER, JANCI BIENVENU (CPNP-PC/AC)
Entity type:Individual
Prefix:
First Name:JANCI
Middle Name:BIENVENU
Last Name:DETWILER
Suffix:
Gender:F
Credentials:CPNP-PC/AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 BURLINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-7414
Mailing Address - Country:US
Mailing Address - Phone:337-224-2123
Mailing Address - Fax:
Practice Address - Street 1:4801 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6917
Practice Address - Country:US
Practice Address - Phone:337-470-2017
Practice Address - Fax:337-470-2809
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08962363LP0222X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP08962OtherSTATE LICENSE