Provider Demographics
NPI:1215223763
Name:BOAL, KELLY CHRISTINE (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CHRISTINE
Last Name:BOAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:DEPT AT952639
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31192-2639
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:405-844-1794
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:405-341-9217
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-11-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA200456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2165623Medicaid
LA2165623Medicaid