Healthcare Provider Details

I. General information

NPI: 1154982171
Provider Name (Legal Business Name): MARY CELESTINE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W CONVENT ST
LAFAYETTE LA
70501
US

IV. Provider business mailing address

113 W CONVENT ST
LAFAYETTE LA
70501-6903
US

V. Phone/Fax

Practice location:
  • Phone: 337-534-0770
  • Fax: 337-534-4370
Mailing address:
  • Phone: 337-534-0770
  • Fax: 337-534-4370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: