Provider Demographics
NPI:1861114407
Name:FUSSELL, ZACHARY BLAKE (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:BLAKE
Last Name:FUSSELL
Suffix:
Gender:M
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6134 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4830
Mailing Address - Country:US
Mailing Address - Phone:318-840-2616
Mailing Address - Fax:
Practice Address - Street 1:1220 PIERREMONT RD STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-1943
Practice Address - Country:US
Practice Address - Phone:318-629-5036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202773363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health