Provider Demographics
NPI:1700412194
Name:LASALLE, EBONY JADE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:JADE
Last Name:LASALLE
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 1:515 S COLLEGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3346
Mailing Address - Country:US
Mailing Address - Phone:337-269-1165
Mailing Address - Fax:
Practice Address - Street 1:515 S COLLEGE RD STE 100
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3346
Practice Address - Country:US
Practice Address - Phone:337-269-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
LA3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant