Provider Demographics
NPI:1528672235
Name:CHAMPAGNE, CALLIE
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:
Last Name:CHAMPAGNE
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 1:3434 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:RACELAND
Mailing Address - State:LA
Mailing Address - Zip Code:70394-3424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3434 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:RACELAND
Practice Address - State:LA
Practice Address - Zip Code:70394-3424
Practice Address - Country:US
Practice Address - Phone:985-859-0612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered