Provider Demographics
NPI:1306399712
Name:CHASE-CIRCELLO, KRYSTLE DANELLE (PA)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:DANELLE
Last Name:CHASE-CIRCELLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 LOUISIANA HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:BATCHELOR
Mailing Address - State:LA
Mailing Address - Zip Code:70715
Mailing Address - Country:US
Mailing Address - Phone:225-492-3775
Mailing Address - Fax:225-492-3782
Practice Address - Street 1:6450 LOUISIANA HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:INNIS
Practice Address - State:LA
Practice Address - Zip Code:70747
Practice Address - Country:US
Practice Address - Phone:225-492-3775
Practice Address - Fax:225-492-3782
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-02
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA302202363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2426982Medicaid