Provider Demographics
NPI:1922203579
Name:LA SALLE, ELIZABETH D'ANTONIO (CRNA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:D'ANTONIO
Last Name:LA SALLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20452
Mailing Address - Street 2:YPS-CREDENTIALING
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-0452
Mailing Address - Country:US
Mailing Address - Phone:614-442-2406
Mailing Address - Fax:614-442-2410
Practice Address - Street 1:42570 S AIRPORT RD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-0946
Practice Address - Country:US
Practice Address - Phone:985-510-6135
Practice Address - Fax:985-510-6202
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN098142367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP01023462OtherRR MEDICARE
LA1024228Medicaid
LA1024228Medicaid