Basic Information
| Provider Information | |||||||||
| NPI: | 1568080166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EZELL | ||||||||
| FirstName: | ERYN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NCPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 HEYMANN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375044279 | ||||||||
| FaxNumber: | 3375044692 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 HEYMANN BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375044279 | ||||||||
| FaxNumber: | 3375044692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2020 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202K00000X | 1072852 | LA | Y | Allopathic & Osteopathic Physicians | Phlebology |
ID Information
| ID | Type | State | Issuer | Description | 1072852 | 01 | LA | NCCT | OTHER |