Provider Demographics
NPI:1396113650
Name:KOLMANSBERGER, STACY LYNETTE
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNETTE
Last Name:KOLMANSBERGER
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 1:37043 OAK HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-0498
Mailing Address - Country:US
Mailing Address - Phone:225-620-3320
Mailing Address - Fax:225-667-4069
Practice Address - Street 1:37043 OAK HAVEN DR
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70706-0498
Practice Address - Country:US
Practice Address - Phone:225-620-3320
Practice Address - Fax:225-667-4069
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA808590343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA34390000XMedicaid