Basic Information
| Provider Information | |||||||||
| NPI: | 1225014665 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTRAND | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | ROY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CFNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROY | ||||||||
| OtherFirstName: | KELLIE | ||||||||
| OtherMiddleName: | CHANTELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8415 GOODWOOD BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708067851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257655728 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 JJJ LN | ||||||||
| Address2: | |||||||||
| City: | SIMMESPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 713692180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189415286 | ||||||||
| FaxNumber: | 3189415284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2005 | ||||||||
| LastUpdateDate: | 05/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN096429 AP04315 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1174882 | 05 | LA | MEDICAID |