Provider Demographics
NPI:1124575014
Name:SHANKLE, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:SHANKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 AMBASSADOR CAFFERY PKWY # 156A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6760
Mailing Address - Country:US
Mailing Address - Phone:337-347-5719
Mailing Address - Fax:281-242-2701
Practice Address - Street 1:330 ALAMO ST STE 7
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8584
Practice Address - Country:US
Practice Address - Phone:337-602-6410
Practice Address - Fax:281-242-2701
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver