Provider Demographics
NPI:1114530722
Name:LANDRY, KALLIE E (PA-C)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:E
Last Name:LANDRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 NEUROSCIENCE CT
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:LA
Mailing Address - Zip Code:70359-5209
Mailing Address - Country:US
Mailing Address - Phone:985-917-3007
Mailing Address - Fax:
Practice Address - Street 1:128 NEUROSCIENCE CT
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:LA
Practice Address - Zip Code:70359-5209
Practice Address - Country:US
Practice Address - Phone:985-917-3007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324145363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant