Basic Information
| Provider Information | |||||||||
| NPI: | 1790449924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRANCH | ||||||||
| FirstName: | DIAMOND | ||||||||
| MiddleName: | KIESHELL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5359 CAMERON BLVD APT B | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701224127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5044309332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 N I 10 SERVICE RD W | ||||||||
| Address2: | |||||||||
| City: | METAIRIE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700066713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774182978 | ||||||||
| FaxNumber: | 8665002186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2021 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.