Basic Information
| Provider Information | |||||||||
| NPI: | 1285802785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN FIRST KIDMED LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN FIRST KIDMED | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1828 W THOMAS ST | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704012958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854192250 | ||||||||
| FaxNumber: | 9854192252 | ||||||||
| Practice Location | |||||||||
| Address1: | 1828 W THOMAS ST | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 704012958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854192250 | ||||||||
| FaxNumber: | 9854192252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | PAT | ||||||||
| AuthorizedOfficialMiddleName: | RANDOLPH | ||||||||
| AuthorizedOfficialTitleorPosition: | PED NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 9854192250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP01814 | LA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.