Provider Demographics
NPI:1922151091
Name:TUMBLIN, CASANDRA KIMBERLAIN (BA)
Entity Type:Individual
Prefix:
First Name:CASANDRA
Middle Name:KIMBERLAIN
Last Name:TUMBLIN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 VIRGINIAN COLONY AVE
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2843
Mailing Address - Country:US
Mailing Address - Phone:985-653-8494
Mailing Address - Fax:985-653-8494
Practice Address - Street 1:1805 VIRGINIAN COLONY AVE
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-2843
Practice Address - Country:US
Practice Address - Phone:985-210-3358
Practice Address - Fax:985-653-8494
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
LA005181316311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1922151091Medicaid