Provider Demographics
NPI:1396186383
Name:MITCHELL, KELLEY GATEWOOD (RPH)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:GATEWOOD
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8309
Mailing Address - Country:US
Mailing Address - Phone:318-387-8933
Mailing Address - Fax:318-387-0179
Practice Address - Street 1:101 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8309
Practice Address - Country:US
Practice Address - Phone:318-387-8933
Practice Address - Fax:318-387-0179
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.013115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist