Provider Demographics
NPI:1225014665
Name:BERTRAND, KELLIE ROY (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:ROY
Last Name:BERTRAND
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:CHANTELLE
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7851
Mailing Address - Country:US
Mailing Address - Phone:225-765-5727
Mailing Address - Fax:225-765-5728
Practice Address - Street 1:118 JJJ LN
Practice Address - Street 2:
Practice Address - City:SIMMESPORT
Practice Address - State:LA
Practice Address - Zip Code:71369-2180
Practice Address - Country:US
Practice Address - Phone:318-941-5286
Practice Address - Fax:318-941-5284
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-19
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN096429 AP04315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1174882Medicaid
LA4C960Medicare PIN
LAQ07481Medicare UPIN