Healthcare Provider Details

I. General information

NPI: 1417536681
Provider Name (Legal Business Name): NICOLE LASSITER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RUSSELL AVE BLDG 41
BELLE CHASSE LA
70037-1006
US

IV. Provider business mailing address

105 CYPRESS PARK LN
BELLE CHASSE LA
70037-1698
US

V. Phone/Fax

Practice location:
  • Phone: 504-678-8234
  • Fax:
Mailing address:
  • Phone: 205-886-4953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD.45391
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: