Provider Demographics
NPI:1255002010
Name:BALTHAZAR, ASHLYN MCKENZIE
Entity Type:Individual
Prefix:
First Name:ASHLYN
Middle Name:MCKENZIE
Last Name:BALTHAZAR
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 1:1301 HORRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:LA
Mailing Address - Zip Code:70668-4531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 HORRIDGE ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:LA
Practice Address - Zip Code:70668-4531
Practice Address - Country:US
Practice Address - Phone:337-324-7017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69341183500000X
LA024813183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist