Provider Demographics
NPI:1033502497
Name:KELLY, LAKEN DESONIER (NP)
Entity Type:Individual
Prefix:
First Name:LAKEN
Middle Name:DESONIER
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 S BEGLIS PKWY
Mailing Address - Street 2:3645 S. BEGLIS PKWY
Mailing Address - City:SULPHUR
Mailing Address - State:LA
Mailing Address - Zip Code:70665-8107
Mailing Address - Country:US
Mailing Address - Phone:337-476-3149
Mailing Address - Fax:
Practice Address - Street 1:3649 S BEGLIS PKWY
Practice Address - Street 2:3645 S. BEGLIS PKWY
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70665-8107
Practice Address - Country:US
Practice Address - Phone:337-476-3149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2384678Medicaid
LA413116YH5NMedicare PIN