1285132043 NPI number — MRS. KIMBERLY LYLES CORMIER RD, LDN

Table of content: MRS. KIMBERLY LYLES CORMIER RD, LDN (NPI 1285132043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285132043 NPI number — MRS. KIMBERLY LYLES CORMIER RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORMIER
Provider First Name:
KIMBERLY
Provider Middle Name:
LYLES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285132043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 S SHERWOOD FOREST BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70816-6038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-526-0002
Provider Business Mailing Address Fax Number:
225-765-9196

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 AMBASSADOR CAFFERY PKWY STE 408
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-6950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-470-3980
Provider Business Practice Location Address Fax Number:
337-470-3989
Provider Enumeration Date:
01/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  2220 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2220 . This is a "STATE LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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