Provider Demographics
NPI:1508010547
Name:DAIGLE, CLYDE LELAND (MSRN, CPNP)
Entity Type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:LELAND
Last Name:DAIGLE
Suffix:
Gender:M
Credentials:MSRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PAYNE ST
Mailing Address - Street 2:
Mailing Address - City:WELSH
Mailing Address - State:LA
Mailing Address - Zip Code:70591-4345
Mailing Address - Country:US
Mailing Address - Phone:337-734-2406
Mailing Address - Fax:
Practice Address - Street 1:100 N PRATER ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2649
Practice Address - Country:US
Practice Address - Phone:337-439-0886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-04
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN071430163W00000X
LAAP03189363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1532703Medicaid