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Get La Standardized Credentialing Application 2012-2025

LOUISIANA STANDARDIZED CREDENTIALING APPLICATION DIRECTIONS Please type or print in black ink when completing this form. If you need more space or have more than four locations attach additional sheets and reference the question being answered. Please see page 9 for a list of required documents. It is very important that you use the month and year for each entity listed. Work history is critical. Failure to provide this information may delay your credentialing. CODE C Clinic/Group S Solo Practice A Academic Paid Teaching Appointments H Civilian Hospital Medical Staff Appointment M Military Service Including Hospital Staff Appointments NAME AND ADDRESS OF ENTITY DATE From MO/YR to MO/YR In the following section please explain any gaps of two months or more in your education post-graduate training or work history PROFESSIONAL LICENSES LICENSE NUMBER DATE OBTAINED EXPIRATION DATE STATE LICENSE FEDERAL DEA REG NUMBER CLIA CERTIFICATE Are laboratory testing procedures as covered by the Clin....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232