Provider Demographics
NPI:1013368794
Name:BORDELON, KIMBERLY PATERNOSTRO
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PATERNOSTRO
Last Name:BORDELON
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 1:28404 LOIRET CT
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-8102
Mailing Address - Country:US
Mailing Address - Phone:985-705-0567
Mailing Address - Fax:
Practice Address - Street 1:180 N 5TH ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2532
Practice Address - Country:US
Practice Address - Phone:985-370-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily