1346867785 NPI number — LACRESHA CLAY EARLEY

Table of content: LACRESHA CLAY EARLEY (NPI 1346867785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346867785 NPI number — LACRESHA CLAY EARLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARLEY
Provider First Name:
LACRESHA
Provider Middle Name:
CLAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1346867785
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
903 WARREN DR
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
WEST MONROE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71291-7158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-217-6521
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 NORTHPARK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-600-3456
Provider Business Practice Location Address Fax Number:
318-600-3456
Provider Enumeration Date:
07/01/2020

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: 363LF0000X , with the licence number:  213885 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0808X , with the licence number: 2133385 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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