=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891718771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARISSA ELTON-LACASSE NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 I-30 BOX
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78185-1672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-698-3300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 843 YELLOW TAVERN CT
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75052-1648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-686-8564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 605266
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------