Healthcare Provider Details

I. General information

NPI: 1366227597
Provider Name (Legal Business Name): ABBY B CUPIT RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2023
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 VILLERE DR
DESTREHAN LA
70047-2513
US

IV. Provider business mailing address

247 VILLERE DR
DESTREHAN LA
70047-2513
US

V. Phone/Fax

Practice location:
  • Phone: 985-210-3571
  • Fax:
Mailing address:
  • Phone: 985-210-3571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3657
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3657
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: