Provider Demographics
NPI:1083067144
Name:WYBLE, KEIFFER BENGIE (AGACNP)
Entity Type:Individual
Prefix:
First Name:KEIFFER
Middle Name:BENGIE
Last Name:WYBLE
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-5939
Mailing Address - Country:US
Mailing Address - Phone:337-988-1585
Mailing Address - Fax:337-981-4694
Practice Address - Street 1:2730 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506
Practice Address - Country:US
Practice Address - Phone:337-988-1585
Practice Address - Fax:337-981-4694
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09352363L00000X, 363LG0600X, 364SR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SR0400XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistRehabilitation
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2468685Medicaid