Provider Demographics
NPI:1689828352
Name:CELESTINE, BRENDA KAYE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAYE
Last Name:CELESTINE
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 1:6521 S MEADOW LARK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70607-0946
Mailing Address - Country:US
Mailing Address - Phone:337-515-7016
Mailing Address - Fax:
Practice Address - Street 1:1717 E PRIEN LAKE RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0400
Practice Address - Country:US
Practice Address - Phone:337-515-7016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACLP.P00122-PHL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory