Provider Demographics
NPI:1558529297
Name:KIRBY, CRISTAL CHANEL (MD)
Entity Type:Individual
Prefix:DR
First Name:CRISTAL
Middle Name:CHANEL
Last Name:KIRBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 COUNTRY CLUB CIR STE B
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-7502
Mailing Address - Country:US
Mailing Address - Phone:318-639-9422
Mailing Address - Fax:318-639-9423
Practice Address - Street 1:164 COUNTRY CLUB CIR STE B
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-7502
Practice Address - Country:US
Practice Address - Phone:318-639-9422
Practice Address - Fax:318-639-9423
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204591208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2155717Medicaid
LA1325074Medicaid