Healthcare Provider Details

I. General information

NPI: 1083067144
Provider Name (Legal Business Name): KEIFFER BENGIE WYBLE AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2016
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506
US

IV. Provider business mailing address

2730 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70506-5939
US

V. Phone/Fax

Practice location:
  • Phone: 337-988-1585
  • Fax: 337-981-4694
Mailing address:
  • Phone: 337-988-1585
  • Fax: 337-981-4694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP09352
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP09352
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code364SR0400X
TaxonomyRehabilitation Clinical Nurse Specialist
License NumberAP09352
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: