Provider Demographics
NPI:1376522425
Name:DUKE, KELLY LINER (PA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LINER
Last Name:DUKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0001
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:2647 S SAINT ELIZABETH BLVD STE 125
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5020
Practice Address - Country:US
Practice Address - Phone:225-647-9675
Practice Address - Fax:225-766-2226
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA200058363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1581666Medicaid
LA200058OtherSTATE LICENSE
LA055655OtherCDS
LATPA132OtherSTATE MEDICAL LIC
LATPA132OtherSTATE MEDICAL LIC