Provider Demographics
NPI:1265289672
Name:ASSAVEDO, SHELBY LYNN
Entity type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:ASSAVEDO
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 1:2405 S LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:VIOLET
Mailing Address - State:LA
Mailing Address - Zip Code:70092-3511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2405 S LAKE BLVD
Practice Address - Street 2:
Practice Address - City:VIOLET
Practice Address - State:LA
Practice Address - Zip Code:70092-3511
Practice Address - Country:US
Practice Address - Phone:504-909-0374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily