Provider Demographics
NPI:1164767398
Name:WARREN, KELLY H (APRN FNP-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:H
Last Name:WARREN
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:HIGGINBOTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5634
Mailing Address - Country:US
Mailing Address - Phone:318-798-4424
Mailing Address - Fax:318-798-4450
Practice Address - Street 1:1114 HOMER RD
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:LA
Practice Address - Zip Code:71055-3028
Practice Address - Country:US
Practice Address - Phone:318-798-4616
Practice Address - Fax:318-798-4619
Is Sole Proprietor?:No
Enumeration Date:2012-11-28
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07048363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2320891Medicaid
LA267562YJS0Medicare PIN