Healthcare Provider Details

I. General information

NPI: 1346886256
Provider Name (Legal Business Name): KELSIE A LAGASSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSIE A DEMERS

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 S WILLOW ST
MANCHESTER NH
03103-5724
US

IV. Provider business mailing address

2501 COTTONTAIL LN
SOMERSET NJ
08873-5125
US

V. Phone/Fax

Practice location:
  • Phone: 603-626-7600
  • Fax:
Mailing address:
  • Phone: 732-529-7120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1112
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: