=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104625532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HER AESTHETICS MEDICAL SPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 03/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 W MORRIS AVE STE B
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70403-4024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-662-8806
-----------------------------------------------------
Fax | 985-214-8232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 604 RUE CANNES
-----------------------------------------------------
City | HAMMOND
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70403-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, MEMBER
-----------------------------------------------------
Name | DR. TABITHA LYNN ACCARDO
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 985-662-8806
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------