Healthcare Provider Details

I. General information

NPI: 1255687927
Provider Name (Legal Business Name): LILLIAN MICHELLE STEPHENS CASTILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 CAPITOL AVE
CROWLEY LA
70526
US

IV. Provider business mailing address

1029 CAPITAL AVE
CROWLEY LA
70526
US

V. Phone/Fax

Practice location:
  • Phone: 337-788-7507
  • Fax: 337-788-7757
Mailing address:
  • Phone: 337-788-7507
  • Fax: 337-788-7577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number868
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number868
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: