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Fleetwood Loustalot

Nurse Practitioner

Physician Assistants & Advanced Practice Nursing Providers

2 Lakeview Cv, Hattiesburg, MS 39402-8528

PECOS Enrollment

Based on the most recent information from CMS, provider Fleetwood Loustalot does not have current enrollment records in PECOS.

Part B
Medicare Part B
Not Enrolled
HHA
Home Health Agency
Not Enrolled
DME
Durable Medical Equipment
Not Enrolled
PMD
Power Mobility Device
Not Enrolled

CMS last updated its PECOS records 5 days ago.

Profile Details

Provider ID
1164470928
Provider Type
Individual
Full Name
Loustalot, Fleetwood
Title
Dr.
Credential
RN, NP-C, PHD

Gender
Male
Sole Proprietor
No
Enumeration Date
5/4/2006
Last Updated
1/5/2008

Contact Information

Practice Location

2 Lakeview Cv, Hattiesburg, MS 39402-8528

(601) 264-2657

Unlisted Fax

Mailing Location

2 Lakeview Cv, Hattiesburg, MS 39402-8528

(601) 264-2657

Unlisted Fax

Provider Taxonomies

Code	Description	License
Code 363LF0000X Primary	Description Nurse Practitioner Physician Assistants & Advanced Practice Nursing Providers	License R864143 Mississippi

Provider Identifiers

ID	Description	Issuer
ID 0126734	Description Medicaid	Issuer Unlisted Mississippi
ID R864143	Description Other	Issuer LICENSE NUMBER Mississippi

Fleetwood Loustalot

PECOS Enrollment

Profile Details

Contact Information

Practice Location

Mailing Location

Provider Taxonomies

Code

Description

License

Code

Description

License

Provider Identifiers

ID

Description

Issuer

ID

Description

Issuer

ID

Description

Issuer

Hutton Healthcare Services

Robertson, Sherri A

Stewart, Felicia S

Dearman, Barbarita Mabel

Delancey, Melinda Bennett

Jackson, Danna Shaye

Wallace, Susan R

Ezelle, Melissa Ann

Carpenter, Avery

Hammons, Joshua Cole