Provider Demographics
NPI:1861583874
Name:MORRIS, DETRIES R (NP)
Entity type:Individual
Prefix:MRS
First Name:DETRIES
Middle Name:R
Last Name:MORRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 1384
Mailing Address - Street 2:115 NORTH JEFFERSON, SUITE B
Mailing Address - City:MANSFIELD
Mailing Address - State:LA
Mailing Address - Zip Code:71052
Mailing Address - Country:US
Mailing Address - Phone:318-871-1633
Mailing Address - Fax:318-871-1677
Practice Address - Street 1:115 NORTH JEFFERSON STREET,
Practice Address - Street 2:SUITE B
Practice Address - City:MANSFIELD
Practice Address - State:LA
Practice Address - Zip Code:71052
Practice Address - Country:US
Practice Address - Phone:318-871-1633
Practice Address - Fax:318-871-1677
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1556548Medicaid
LA582000630OtherEIN
LA582000630OtherEIN
LA1556548Medicaid
LA5X936Medicare PIN