Provider Demographics
NPI:1639362650
Name:CHIMENTO, KRISTINE FALCON (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:FALCON
Last Name:CHIMENTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KRISTINE
Other - Middle Name:
Other - Last Name:FALCON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:107 MONTROSE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 MONTROSE AVE STE D
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3852
Practice Address - Country:US
Practice Address - Phone:337-981-9316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203118208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1005398Medicaid