Provider Demographics
NPI:1396797015
Name:AYCOCK, KATHERINE (CRNA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:AYCOCK
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 250
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70571-0250
Mailing Address - Country:US
Mailing Address - Phone:337-943-7128
Mailing Address - Fax:337-407-9645
Practice Address - Street 1:5101 HIGHWAY 167 S
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-8980
Practice Address - Country:US
Practice Address - Phone:337-943-7128
Practice Address - Fax:337-407-9645
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN024176367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA56522Medicare ID - Type Unspecified