Basic Information
| Provider Information | |||||||||
| NPI: | 1942223862 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESSELLE | ||||||||
| FirstName: | BONNIE | ||||||||
| MiddleName: | CLAIRE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HENRY CLAY AVE | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701185720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044121835 | ||||||||
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| Practice Location | |||||||||
| Address1: | PEDIATRIC PULMONARY AND CRITICAL CARE ASSOCIATES | ||||||||
| Address2: | 200 HENRY CLAY AVE | ||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5048969263 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 12/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 019870 | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | 019870 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1661473 | 05 | LA | MEDICAID | 00126659 | 05 | MS | MEDICAID |