Provider Demographics
NPI:1245736453
Name:HAVARD, KELLY (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HAVARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10876 HIGHWAY 109
Mailing Address - Street 2:
Mailing Address - City:STARKS
Mailing Address - State:LA
Mailing Address - Zip Code:70661-5002
Mailing Address - Country:US
Mailing Address - Phone:337-222-0092
Mailing Address - Fax:
Practice Address - Street 1:3236 KIRKMAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8640
Practice Address - Country:US
Practice Address - Phone:337-478-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA219543163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse