Provider Demographics
NPI:1164975959
Name:KELLY, BRITTANY ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:ELAINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:ELAINE
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:902 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5830
Practice Address - Country:US
Practice Address - Phone:318-513-1950
Practice Address - Fax:318-513-1952
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant