=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255812160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEYOTA ANDREA RUSSELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2018
-----------------------------------------------------
Last Update Date | 09/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2408 HOUMA BLVD APT 315
-----------------------------------------------------
City | METAIRIE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-261-2811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7001 BUNDY RD APT R10
-----------------------------------------------------
City | NEW ORLEANS
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70127-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 504-261-2811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number | 0083422717
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------