Provider Demographics
NPI:1457716151
Name:DIBBLE, KRISTY LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LEIGH
Last Name:DIBBLE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4550 NORTH BLVD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-4013
Mailing Address - Country:US
Mailing Address - Phone:225-926-1269
Mailing Address - Fax:225-927-7367
Practice Address - Street 1:4560 NORTH BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4043
Practice Address - Country:US
Practice Address - Phone:225-928-0695
Practice Address - Fax:225-341-5903
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP05714363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA478892Medicare PIN