1497124325 NPI number — MRS. ELIZABETH KEYS CASSELBERRY NP

Table of content: MRS. ELIZABETH KEYS CASSELBERRY NP (NPI 1497124325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497124325 NPI number — MRS. ELIZABETH KEYS CASSELBERRY NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSELBERRY
Provider First Name:
ELIZABETH
Provider Middle Name:
KEYS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KEYS
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
CLAIRE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1497124325
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2051 SILVERSIDE DR
Provider Second Line Business Mailing Address:
STE 260
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70808-9005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-490-6301
Provider Business Mailing Address Fax Number:
225-765-9539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5131 ODONOVAN DR
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70808-4782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-765-7778
Provider Business Practice Location Address Fax Number:
225-765-7754
Provider Enumeration Date:
09/22/2015

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: 363LP0808X , with the licence number:  AP08524 , 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)





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