Healthcare Provider Details

I. General information

NPI: 1992494645
Provider Name (Legal Business Name): MALLORY CHRICEOL RN, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TRAVIS ST #138
LAFAYETTE LA
70503
US

IV. Provider business mailing address

136 COUNTRY VILLAGE DR
YOUNGSVILLE LA
70592
US

V. Phone/Fax

Practice location:
  • Phone: 337-257-3171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number205269
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: