Healthcare Provider Details

I. General information

NPI: 1306399712
Provider Name (Legal Business Name): KRYSTLE DANELLE CHASE-CIRCELLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77575 LANDRY DR
MARINGOUIN LA
70757-3210
US

IV. Provider business mailing address

6450 LA HIGHWAY 1 STE B
BATCHELOR LA
70715-3212
US

V. Phone/Fax

Practice location:
  • Phone: 225-625-2105
  • Fax: 225-625-2109
Mailing address:
  • Phone: 225-618-5015
  • Fax: 225-442-3107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number302202
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: